Rr^\A 


M^6 


Columbia  ^ntben^fti) 


(gift  nf  ir.  SloBf pij  A.  llak? 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

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http://www.archive.org/details/collectionofpape01mayo 


William  J.  Mayo  at  Graduation,  iS 


William  J.  Mayo. 


Charles  H.  Mayo  at  Graduation,  1887. 


Charles  H.  Mayo. 


A  COLLECTION  OF  PAPERS 

Published  Previous  to  1909 


By 

WILLIAM  J.  MAYO 

and 

CHARLES  H.  MAYO 


VOLUME    I 


PHILADELPHIA  AND  LONDON 

W.  B.   SAUNDERS    COMPANY 

1912 


Copyright,  1912,  by  W.  B.  Saunders  Company 


PRINTED  IN  AMERICA 


FOREWORD 

III  llic  |)lH'|);ii;il  loll  <)l  lliis  \()|iiiiic,  "A  (  Ollcrl  loii  of  |',i|)crs," 
the  editor  Ims  heeii  inlliieiiced  hy  the  desire  to  collcet  mikI  jtreserve 
a  complete  file  of  the  \\riliri<is  of  NVilliaiii  .lames  Mayo  and  ("liarh's 
Horace  Mayo  from  the  lime  (»f  their  ^rathiation  from  Medical 
Collef^e  to  Fehriiar\',  !!)()!),  the  dale  of  the  jjnhhcal  ion  of  the 
first  vohime  of  "("olk'cted  I'apers  hy  Ihe  SlafV  of  Si.  Mary's 
IIospitaL"  This  hitter  vohime  (hd  not  coiilain  all  of  Ilic  arlides 
written  hy  the  Doctors  Mayo  hetwecii  the  years  !!)().>  and  11)0!), 
hut  only  some  of  the  more  im|)ortant  ones  taken  from  the  journal 
files.  This  explains  why  papers  of  a  date  later  than  l!)().j  are  to  he 
found  in  the  present  collection. 

The  fj;eneral  phm  of  chissification  used  in  the  hrsl  \-oliinie  of 
"Collected  Papers"  has  been  retained  in  the  arrangement  of  the 
"Old  I'apers,"  with  the  addition  of  various  suhluNidin^rs  to  accom- 
modate the  more  diverse  character  of  the  writin<,'s.  The  papers 
under  each  cla.ssification,  or  subject  headin<f,  have  l)een  placed  in 
chronologic  order,  thus  marking  points  in  the  develof)ment  of  the 
work  of  the  Doctors  Mayo,  and  also  recording  interesting  historic 
events  in  the  progress  of  general  surgery  from  the  date  of  the 
earliest  papers,  written  in  1884,  to  the  pre.sent  time. 

In  the  final  arrangement  of  the  material  various  short  article.s 
and  rejjorts  of  cases  have  been  omitted,  particularly  when  the 
data  ajjpeared  to  l)e  incorporated  in  later  articles.  However,  the 
editor  has  conscientiously  endeavored  to  incorporate  into  the 
collection  all  of  the  original  subject  matter,  while  at  the  same 
time  she  carefully  avoided  any  changes  which  would  appear  to 
indicate  an  attemj)t  to  bring  such  subject  matter  "uj)  to  date." 

The  accumulation  of  this  material  was  begun  some  four  years 
ago.  Every  possible  clue  has  been  followed  and  unraveled  in  the 
hoj)c  of  securing  "just  one  more  article."  That  these  clues  have 
been  ])articularly  evasive  is  due  in  part  to  the  fact  that  no  record 
had  l)een  kept  of  these  early  papers,  and  in  ])art  to  the  somewhat 
defective  arrangement  and  lack  of  indexing  of  the  older  medical 
journals.  Herewith  the  editor  wishes  to  acknowledge  her  appreci- 
ation of  the  courteous  coo|)eration  of  the  editors  of  these  journals 
in  assisting  her  to  find,  in  their  old  files,  articles  not  included  in 
the  Index  Medicus. 

Mrs.  M.  II.  Mellisii.  Kdiior. 

Rochester,  Minnesota, 
May,  1912. 


CONTENTS  OF  VOLUME  I 


Alimentary  Canal  pace 

Foreign  Bodies  ix  the  Trachea  and  Esophagus 3 

Removal  of  an  Open  Hickle  Impacted  in  the  Esophagus  (with  A'-ray 

Skiagraph) 10 

Cicatricial  Stricture  ok  the  Esophagus 11 

Stomach 

Surgery  of  the  Stomach 33 

Some  Mechanical  Causes  of  Interference  with  the  Action  of  the 

Stomach  and  Their  Surgical  Relief 43 

Cicatricial  Stenosis  and  Valve  Formation  a  Cause  of  Pyloric  Ob- 
struction       50 

Observations  on  the  Diagnosis  and  Surgical  Treatment  of  Certain 

Diseases  of  the  Stomach 62 

The   Diagnosis  and   Surgical  Treatment  of   Malignant  Obstruction 

of  the  Pylorus 71 

The  Surgical  Treatment  of  Diseases  of  the  Stomach 82 

Malignant   Diseases   of  the  Stomach  and  Pylorus 93 

Lymphatic  Involvement  in  Cancer  of  the  Stomach 119 

Some  of  the  Diseases  Common  to  the  Stomach:    Their  Surgical  Treat- 
ment     121 

Some  Indications  for  Gastro-enterostomy 132 

Problems  Relating  to  Surgery  of  the  Stomach 139 

Complications  Following  Gastro-enterostomy 148 

The  Radical  Cure  of  Cancer  of  the  Stomach 161 

The  Present  Status  of  Surgery  of  the  Stomach 169 

A  Review  of  303  Operations  upon  the  Stomach  and  First  Portion  of 

THE  Duodenum 178 

Chronic  Ulcer  of  the  Stomach  and  Duodenum  from  a  Surgical  Stand- 
point      1 94 

Radical  Operations  for  the  Cure  of  Cancer  of  the  Pyloric  End  of  the 

Stomach 207 

V 


VI  CONTENTS 

PAGE 

Ulcer  and  Cancer  of  the  Stomach  from  a  Surgical  Standpoint 218 

The  Association  of  Surgical  Lesions  in  the  Upper  Abdomen 231 

Duodenal  Ulcer:     A   Clinical  Review  of  58  Operated   Cases,   with 

Some  Remarks  on  Gastrojejunostomy 244 

A  Review  of  500'  Cases  of  Gastro-enterostomy,  Including  Pyloroplasty, 

Gastroduodenostomy,  and  Gastrojejunostomy 253 

Chronic  Ulcer  of  the  Stomach  and  First  Portion  of  the  Duodenum, 

WITH  Especial  Reference  to  the  Surgical  Treatment 267 

The  Surgical  Treatment  of  Cancer  of  the  Stomach.     Report  of  100 

Gastric  Resections 279 

The  Technic  of  Gastrojejunostomy 293 

The  Surgical  Treatment  of  Gastric  and  Duodenal  Ulcer     and     Its 

Results 299 

The  Principles  Underlying  the  Surgery  of  the  Stomach  and  Asso- 
ciated Viscera - 308 

Liver  and  Gall-bladder 
Report  of  Two  Operations  for  the  Relief  of  Gall-stones  and  One 

for  Stricture  of  the  Common  Duct  of  the  Liver 327 

Complete  Obstruction  of  the  Common  Duct  of  the  Liver.  Anastomosis 
between  the  Gall-bladder  and  Jejunum  by  Means  of  Murphy's 

Button 330 

Surgery  of  the  Gall-bladder,  Cystic  and  Common  Ducts,  with  Report 

of  Seven  Cases  Operated  upon 331 

Gall-stone  Disease 336 

A  Case  of  Gunshot  Wound  of  the  Liver.  Immediate  Operation.  Re- 
covery     346 

Some   Observations    on    the    Surgery    of  the  Gall-bladder  and  the 

Bile-ducts 348 

Cholecystectomy,  with  Especial  Reference  to  the  Removal  of  the 

Mucous   Membrane   of  the  Gall-bladder  as  a  Substitute 355 

The  Surgical  Significance  of  Jaundice 360 

Cancer  of  the  Common  Bile-duct.  Report  of  a  Case  of  Carcinoma  of 
THE  Duodenal  End  of  the  Common  Duct  with  Successful  Exci- 
sion     364 

A  Study  of  328  Operations  upon  the  Gall-bladder  and  Bile-passages  372 

Malignant  Disease  Involving  the  Gall-bladder 384 

The  Present  Status  of  Surgery  of  the  Gall-bladder  and  Bile-ducts  392 
Malignant  Disease  of  the  Common  Bile-duct 401 


CONTENTS  VII 

PAGE 

A  Study  ok  '>'M  Oi-kuations  i  i-on  tiik  (i  M.i.-iii,\i)iJi;it  and  Hii.k-passage», 

WITH  Tabulatkd  Rep(jht  ok  547  Oi'KKated  Cases 407 

Some  Causes  ok  Failure  ok  Operation  to  Cure  Gallstone  Disease.  410 
Some  0bsf:rvation8  on  the  Surgery  ok  the  Common  Duct  ok  the  Liver  ii\ 
A  Review  ok  1000  Operations  kor  Oam^stone  Disease,  with  Special 

Rekerence  to  the  Mortality 430 

The  Diagnosis  ok  Gall-stone  Disease 438 

Some  Observations  on  Cases  Involving  Operative  Loss  ok  Continuity 
OK  the  Common  Bile-duct,  with  the  Report  ok  a  Case  ok  Anasto- 
mosis  BETWEEN   THE   HePATIC   DuCT   AND  THE  DuODENUM 440 

A  Review  ok  1500  Operations  upon  the  Gall-bladder  and  HiLE-PASsAGta, 

WITH  Especial  Rekerence  to  the  Mortality i5i 

Pancreas 

Case  ok  Acute  Pancreatitis  with  Fat  Necrosis — Operation:    Recovery  401 

Pancreatic  Cyst 404 

The  Surgical  Aspect  of  Pancreatitis 4G0 


Bibliographic  Index 473 

Index  ok  Subjects 479 


ALIMENTARY  CANAL 


ESOPHAGUS 


VOL.  I —      1 


FOREIGN    BODIES    IN    THE    TRACHEA    AND 
ESOPHAGUS* 


CHARLES    H.    MAYO 


I  speak  of  these  organs  under  the  same  heading  because  of  their 
intimate  structural  relations,  which  often  complicate  early  diag- 
nosis of  the  location  of  foreign  bodies  or  the  remote  results  of 
secondary  changes.  The  difficulties  in  the  diagnosis  and  treat- 
ment, with  the  attending  responsibility,  render  these  cases  very 
serious  to  the  physician  and  to  all  concerned.  The  foreign  bodies 
most  frequently  met  wdth  are  seeds  and  other  things  of  a  vegetable 
nature  capable  of  swelling,  bones,  and  metallic  bodies. 

In  children  it  frequently  happens  that  either  the  character  or 
the  location  of  the  offending  body  is  a  matter  of  conjecture,  and 
the  symptoms  may  be  so  slight  as  to  mislead  the  physician.  At 
a  later  period  a  dislodgment  of  the  irritant  may  possibly  produce  a 
fatal  laryngeal  spasm,  in  the  one  case,  or  ulceration  of  the  esopha- 
gus, in  the  other. 

A  foreign  body  high  in  the  esophagus  may,  through  local  change 
and  swelling,  simulate  a  foreign  body  in  the  trachea,  or  a  tracheal 
body,  by  lodgment  and  temporary  amelioration  of  the  symptoms, 
may  lead  to  the  belief  that  a  passing  esophageal  obstruction  is  the 
cause  of  the  trouble;  therefore,  where  the  character  and  location 
of  the  foreign  body  are  unknown,  it  is  well  to  pass  the  esophageal 
bougie  to  make  a  differential  diagnosis. 

Foreign  bodies  which  have  entered  the  air-passages  may  lodge 
at  any  point  between  the  larynx  and  smaller  bronchi.  The  symp- 
toms of  foreign  bodies  in  the  trachea  vary  with  their  size,  shape, 
and  location,  and  they  may  be  intense  or  extremely  mild.     The 

*  Reprinted  from  "Trans.  Minn.  State  Med.  Society,"  1S96,  p.  1-26. 

3 


4  CHARLES    H.    MAYO 

early  symptoms  are  spasm  of  the  larynx,  choking,  cough,  and  res- 
piratory distress.  Vomiting,  and  usually  more  or  less  shock,  may 
occur.  Bloody  mucus  may  be  raised  immediately,  and  fatal 
dyspnea  often  speedily  follows  from  the  laryngeal  spasm,  or  the 
large  size  of  the  foreign  body  may  almost  completely  occlude  the 
trachea,  as  in  Case  I. 

Violent  efforts  on  the  part  of  the  patient  may  sometimes  dis- 
lodge and  expel  the  irritant,  but  more  often  it  will  serve  only  to 
add  to  the  distress  and  exhaustion.  If  the  foreign  body  becomes 
fixed,  the  symptoms  tend  to  subside,  thereby  leading  attendants 
to  believe  that  it  has  been  expelled,  until,  later,  a  change  of  the 
position  causes  a  recurrence  of  the  urgent  symptoms,  as  in  Case  2. 

The  diagnosis  is  often  difiicult  in  children,  but  the  suddenness 
of  the  attack,  absence  of  temperature,  and  comparative  relief  to 
the  patient  between  the  attacks  of  dyspnea,  combined  with  the  aid 
of  auscultation  and  laryngoscqpic  examination,  will  assist  in  the 
making  of  a  positive  diagnosis. 

The  prognosis  is  exceedingly  grave,  and  depends  to  a  great  ex- 
tent upon  how  early  the  patient  is  subjected  to  treatment.  The 
dangers  are  from  the  immediate  obstruction  and  the  secondary 
septic  complications,  which  are  more  serious  in  the  child  than  in 
the  adult. 

A  foreign  body  in  one  of  the  bronchi,  unless  removed,  will 
almost  certainly  destroy  life,  either  suddenly  or  through  lung  com- 
plications, such  as  bronchitis,  septic  pneumonia,  gangrene,  abscess, 
or  perforation  of  the  neighboring  structures. 

We  may  properly  divide  these  cases  into  two  classes  for  treat- 
ment: First,  where  the  foreign  body  is  known  to  have  lodged  in 
the  trachea  or  bronchus,  in  which  case  there  is  no  doubt  as  to  the 
necessity  of  operative  interference;  second,  those  cases  in  which  a 
positive  early  diagnosis  is  not  possible  and  necessitates  delay  until 
physical  signs  and  symptoms  verify  the  probable  diagnosis. 

The  diagnosis  determining  the  operation  should  not  be  delayed, 
no  matter  how  mild  the  symptoms.  The  method  often  advocated, 
of  shaking  a  child  by  the  heels  and  pounding  him  on  the  back,  is 
unwise  unless  the  physician  is  prepared  to  make  immediate  trache- 


P'OUEUiN     HODIKS    IN     TUACIIKA     AM)     IXM'IIACIH  .> 

otomy  for  the  relief  of  sj)iisiii  of  the  glottis.  Foreign  bodies 
loeated  in  the  larynx  or  high  in  the  trarhea  ean  he  removed 
through  tlic  mouth  l)y  means  of  tli(>  laryngoscope  and  projtcr 
instruments.  "  These  do  not,  as  a  rule,  form  the  urgent  ca.ses,  as 
the  foreign  })ody  may  remain  high  in  the  traehea  for  long  periods 
without  exeiting  dangerous  .symptoms.  Tracheotomy  is  neces- 
sary for  the  removal  of  foreign  bodies  thai  liaxc  passed  the  glottis, 
whether  lodged  high  or  low.  The  high  tracheotomy,  or  division 
of  the  upper  two  tracheal  rings,  may  be  preferred  in  children  with 
short  necks,  while  in  ordinary  cases  the  low  tracheotomy,  or  divi- 
sion of  the  second  three  traelieal  rings,  will  prove  more  advantage- 
ous. 

The  performance  of  tracheotomy  with  the  Paquelin  cautery  or 
by  the  use  of  some  mechanical  device  is  out  of  i)lace  in  this  class  of 
ca.ses.  The  points  to  be  emphasized  in  the  [)erformance  of  trache- 
otomy after  exposing  the  trachea  are:  First,  the  insertion  of  a 
tenaculum  in  the  median  line  of  the  trachea  above  the  point  of 
expected  incision,  with  the  traction  u])ward;  second,  a  stab  j^unc- 
ture  of  the  trachea  and  cutting  upward;  third,  avoidance  of  in- 
jury to  the  esophagus  by  too  deep  an  incision;  fourth,  retention 
of  knife  in  tracheal  incision  until  the  opening  is  secured  by  other 
instruments. 

Chloroform  is  preferred  as  an  anesthetic,  since  it  relieves  laryn- 
geal spasm.  Anesthesia  is  not  necessary  in  operating  during  a 
suffocative  attack.  The  use  of  a  probe  to  loosen  a  foreign  body  or 
excite  cough,  as  in  Case  1,  as  well  as  the  posture  of  the  patient,  may 
prove  of  advantage. 

If  the  foreign  body  is  removed,  the  Avound  will  recpiire  little 
care.  Our  method  is  to  pack  the  wound  lightly  with  iodoform 
gauze.  If  unable  to  remove  the  annoying  agent,  as  frecpiently 
occurs,  the  sides  of  the  trachea  may  be  stitched  to  the  skin  and  the 
opening  maintained  for  a  day  or  two.  The  irritant  will  be  ejected 
usually  within  a  few  hours. 

From  a  considerable  ex])erience  in  the  removal  of  foreign  bodies 
from  the  trachea  I  have  selected  three  illustrative  cases  for  the 
purpose  of  eliciting  discussion. 


6  CHARLES    H.    INIAYO 

Case  1.— C.  F.,  male,  aged  six  years.  After  wearing  an 
O'Dwyer  intubation  tube  No.  3  six  days  for  the  relief  of  so-called 
membranous  croup,  the  swelling  left  the  larjoix,  allowing  the 
tube  to  pass  between  the  vocal  cords,  where  it  lodged  in  the 
upper  part  of  the  trachea.  Upon  attempting  to  remove  it  through 
the  mouth  it  shpped  down  into  the  bronchus,  producing  a  severe 
attack  of  dyspnea.  Respiration  ceased  completely  in  about  fifteen 
minutes,  and  just  before  the  incision  of  a  low  tracheotomy  was 
made.  The  trachea  was  held  open  by  forceps,  the  child  held 
up  by  the  heels,  and  a  probe  inserted  into  the  right  bronchus, 
where  it  loosened  the  tube  and  excited  spasmodic  coughing, 
aiding  the  dislodgment.  The  tube  slipped  into  the  trachea  and 
was  withdra^\'n  through  the  tracheal  wound.  Artificial  respiration 
was  maintained  for  about  twenty  minutes,  and  then  the  breath- 
ing became  natural;  a  tracheotomy  tube  was  inserted  and  allowed 
to  remain  six  days.  Recovery  was  perfect,  although  delayed  by 
a  septic  bronchitis. 

Case  2. — C.  C,  female,  aged  two  years.  This  child,  while 
playing  with  citron  seeds,  had  an  attack  of  suffocation  which  was 
so  severe  that  her  parents  though  she  was  dead.  She  soon  recov- 
ered, however,  only  to  have  slightly  less  severe  attacks  at  intervals. 
After  three  days  the  child  was  brought  to  St.  Mary's  Hospital, 
where,  from  the  history  and  symptoms  present,  a  diagnosis  of 
foreign  body,  probably  citron  seed,  loose  in  the  trachea,  was  made. 
A  low  tracheotomy  enabled  me  to  dislodge  a  swollen  citron  seed, 
which  was  removed  with  forceps.     The  recovery  was  uneventful. 

Case  3. — M.  M.,  male,  aged  one  and  one-half  years,  was 
brought  to  me  with  this  history:  Three  days  previously,  while 
playing  in  the  yard,  he  was  seized  with  a  severe  spell  of  suffocation. 
There  was  nothing  about  him  to  indicate  the  cause  of  the  attack, 
which  was  followed  by  many  others.  A  diagnosis  of  foreign  body 
of  unknown  character  in  the  trachea  was  made.  A  low  trache- 
otomy was  performed,  and  a  swollen  kernel  of  corn  was  coughed 
up  into  the  opening,  where  it  was  fixed  by  a  curved  probe  and 
removed  with  forceps. 

While  foreign  bodies  in  the  esophagus  are  not  primarily  so 
dangerous  as  in  the  trachea,  the  remote  results  are  very  serious, 
and  the  foreign  bodies  themselves  are  as  varied,  with  a  predomi- 
nance of  artificial  dentures,  coins,  bones,  the  larger  fruit-stones. 


FOREIGN    IJOniKS    IN    TUArriKA    AM)    KSOPHAGUS  7 

and  temponiry  ol)slnicli()ii  from  food  holiis.  The  impaction  of 
the  forci^'ii  hody  in  I  he  csoplia^Mis  gctK-rally  takes  place  at  its 
narrowest  portion,  at  I  lie  le\'el  of  the  cricoid  cartilage,  and  next  in 
frequency  at  the  cardiac  end,  !)ut  may  occur  at  any  point.  The 
symptoms  depend  upon  the  size  and  shajjc  of  the  foreign  body. 
If  large  and  smooth,  sudden  death  may  occur  from  j)ressurc  upon 
the  aperture  of  the  huyiix  or  from  spasm  of  the  glottis.  If  j)ointed 
and  irregular,  there  will  be  dyspliagia  or  complete  obstruction. 
l)y.si)nca  and  a  constant  di.scharge  of  saliva  and  nmcus,  with  ten- 
derness of  the  neck  and  soreness  behind  the  sternum,  may  occur. 
If  left  to  itself,  the  foreign  body  excites  inflammation,  which  often 
leads  to  its  dislodgmcnt,  but  more  frequently  complicates  matters 
by  extending  into  the  neighboring  tissues,  causing  perforation  into 
the  pleura,  trachea,  mediastinum,  or  aorta.  When  the  foreign 
bod}'  is  large,  the  diagnosis  is  comparatively  simple.  The  exploring 
finger  can  reach  as  far  as  the  arytenoid  cartilages.  When  situated 
below  this  point,  its  presence  must  be  decided  by  inference,  aided 
by  esophageal  sounds,  stomach-tube,  etc. 

Always  bear  in  mind  that  symptoms  of  the  presence  of  a  foreign 
body  in  the  esophagus  may  be  simulated  by  irritation  of  the  mucous 
membrane,  caused  by  the  passage  into  the  stomach  of  the  foreign 
body,  the  sensation  existing  long  after  its  dislodgraent.  When  it 
can  be  done  safely,  the  foreign  body  may  be  extracted  through  the 
mouth.  If  unable  to  remove  it  in  this  manner  and  it  can  be  easily 
pushed  down  into  the  stomach,  this  may  be  done.  If  neither 
method  avails  without  the  use  of  undue  violence,  an  external 
esophagotomy  should  be  performed  and  the  body  extracted  through 
the  opening.  Sometimes  during  the  manii)ulations  of  removal 
the  foreign  body  is  ejected  by  the  severe  ^•omiting  and  retching 
l)roduced,  but  emetics  should  not  be  given  for  this  ])urpose,  as  the 
esophagus  has  been  known  to  be  ruptured  by  violent  vomiting. 

Various  instruments,  such  as  expanding  sponge  probang,  long 
forceps,  blunt  hook  or  coin-catcher,  and  soft-rubber  stomach- 
tube,  have  been  employed  to  dislodge  the  obstruction.  In  cases 
of  obstruction  by  bodies  of  an  irregular  character  the  swallowing 
of  a  knotted  skein  of  thread  fastened  to  a  strong  cord  will  often 


8  CHARLES   H.    IMAYO 

entangle  the  foreign  body  in  its  meshes  upon  its  withdrawal.  An 
external  esophagotomy  is  much  safer  than  violent  efforts  at  ex- 
traction or  forced  attempts  to  push  it  downward.  Other  attempts 
at  removal  having  failed,  operation  should  be  made  not  later  than 
twenty-four  hours  after  diagnosis  of  impacted  foreign  body.  The 
operation  of  external  esophagotomy  is  usually  made  on  the  left 
side  of  the  neck;  carefully  separating  the  tissues  between  the  great 
vessels  and  trachea,  and  avoiding  the  inferior  laryngeal  nerve,  the 
esophagus  is  forced  into  the  wound,  and  its  opening  readily  effected. 
If  necessary,  a  finger  can  be  introduced  through  the  opening  for 
the  purpose  of  exploration,  as  in  Case  2. 

In  case  of  impaction  low  down  in  the  esophagus  a  gastrotomy 
may  be  combined  with  an  external  esophagotomy  and  the  body 
loosened  from  below.  If  necessary,  the  hand  may  be  inserted 
into  the  stomach  to  effect  its  dislodgment,  as  recommended  by 
Richardson,  or  gastrotomy  will  admit  a  probe  passed  from  below, 
by  the  obstruction  through  the  opening  of  the  esophagus,  carrying 
a  string  -^dth  a  sponge  attached,  which,  upon  its  withdrawal,  may 
raise  the  obstruction  sufficiently  for  its  removal — the  latter  method 
being  similar  to  the  Abbe  string  method  of  dividing  strictures  of 
the  esophagus.  The  wound  is  dressed  with  a  light  iodoform 
gauze  pack,  which  serves  the  purpose  of  drainage  and  prevents 
discharge  during  the  process  of  deglutition.  The  healing  occurs  by 
granulation,  immediate  suture  not  being  safe. 

The  following  case  reports  illustrate  the  three  ordinary  methods 
of  removing  foreign  bodies  from  the  esophagus. 

Case  1. — E.  L.,  male,  aged  sixty-five  years.  Entered  St. 
Mary's  Hospital  to  be  relieved  of  the  major  part  of  the  breast 
bone  of  a  chicken  impacted  in  his  esophagus  for  six  days.  He 
was  in  bad  condition,  due  to  repeated  attempts  to  force  the  body 
do'RTLward.  It  was  lodged  opposite  the  cricoid  cartilage,  and  was 
removed  after  fracture  of  one  wing  by  forceps,  using  the  finger 
as  a  guide. 

Case  2. — W.  C.  K.,  male,  aged  fifty-three  years.  Came  to 
the  office  ^\nth  a  portion  of  an  oyster-shell  caught  in  his  esophagus. 
The  obstruction  was  only  of  a  few  hours'  duration,  but  the  patient 


FOREIGN    BODIES    IN    TRACHEA    AND    ESOPHAGUS  9 

was  suffering  severely.  The  obstruction  was  readily  passed  into 
the  stomach  by  the  safe  pressure  produced  by  the  soft-rubber 
tube. 

Case  3.-^C.  A.,  female,  aj^'cd  three  years.  Was  brought  to 
St.  Mary's  Hospital  with  complete  obstruction  of  the  esophagus 
I)roduced  by  an  impacted  prune-stone.  The  esophageal  sound 
located  the  stone  at  the  middle  of  the  esophagus.  .Ml  attempts 
to  remove  it  through  the  mouth  with  forcei)s  and  hooks  having 
failed,  a  low  e.vternal  esophagotomy  enabled  us  to  get  at  the  foreign 
body,  which  was  situated  three  inches  below  the  opening,  and 
remove  it.  Recovery  was  uneventful,  the  wound  granulating 
in  about  two  weeks. 

'J'he  successful  treatment  of  three  cases  of  cicatricial  strictures 
of  the  esophagus  by  external  esophagotomy  combined  with  gastrot- 
omy,  the  passing  of  probes,  and  the  use  of  string  dilators,  has 
demonstrated  the  advantage  of  this  method  in  giving  access  to 
all  parts  of  the  lower  esophagus. 


REMOVAL  OF  AN  OPEN  BUCKLE   IMPACTED 
IN  THE  ESOPHAGUS  (WITH  Z-RAY 
SKIAGRAPH)* 


CHARLES    H.    MAYO 


The  report  of  the  following  case,  with  the  accompanying  skia- 
graph, is  an  indication  of  the  future  usefulness  of  the  Rontgen  rays 
in  practical  surgery. 

M.  F.,  aged  three  years,  was  brought  to  St.  Mary's  Hospital 
January  7,  1897,  for  the  removal  of  a  buckle  which  had  been  im- 
pacted in  the  esophagus  for  three  days  without  attempt  at  removal. 
A  skiagraph  was  made  of  the  child's  chest,  which  showed  the 
buckle  plainly  visible,  open,  its  teeth  projecting  up  and  to  the 
right,  just  behind  the  upper  part  of  the  sternum  (Fig.  1).  A  left 
esophagotomy  enabled  me  to  effect  its  removal  by  hooking  a  bent 
probe  into  a  loop  of  the  buckle  and  extracting  it,  blunt  end  first. 
The  wound  was  packed  with  gauze,  and  the  patient  made  an 
uneventful  recovery,  leaving  the  Hospital  January  20,  1897. 

While  it  was  known  that  the  patient  swallowed  a  buckle  and 
had  an  obstruction  of  the  esophagus,  the  points  of  value  to  be 
ascertained  were  the  location  of  the  buckle,  and  whether  or  not 
it  was  open.  The  former  could  easily  be  ascertained  by  an  eso- 
phageal bougie,  but  not  the  latter.  The  bougie  might  be  harmful, 
should  the  buckle  be  open,  by  forcing  the  points  through  the  wall 
of  the  esophagus.  The  danger  of  its  removal  by  grasping  with 
forceps  through  the  mouth  and  drawing  up  the  points  impacted  in 
the  wall  of  the  esophagus  for  three  days  will  be  readily  seen.  The 
child  was  exposed  to  the  a;-ray  twenty  minutes  while  asleep  in  its 
mother's  arms,  without  removing  any  but  the  outer  clothing.  The 
dark  center  of  the  radiograph  is  caused  by  the  spine,  and  the  shadow 
of  the  heart  renders  it  larger  below.  The  buttons  of  the  clothing 
are  easily  distinguished  (Fig.  1). 

*  Reprinted  from  "Northwestern  Lancet,"  1897,  xvii. 
10 


Fij:.  I.— Skiiisraph  showing'  opin  buckle  impactetl  in  the  esophagus. 


CICATRICIAL  STRICTURE  OF  THE 
ESOPHAGUS* 

WILLIAM    J.    MAYO 


The  inaccessible  situation  of  the  gullet,  its  relation  to  impor- 
tant structures,  and  the  difficulty  attending  manipulations  within 
its  narrow  lumen,  all  tend  to  place  esophageal  obstruction  among 
the  surgical  problems  which  are  difficult  of  solution.  The  cases 
are  sufficiently  rare  to  render  an  individual  experience  incomplete, 
and  yet  are  frequent  enough  to  stimulate  our  best  endeavor  for 
their  relief. 

Konig  makes  a  verj'  practical  classification  of  esophageal  ob- 
structions into:  (1)  Those  located  within  the  esophagus,  such  as 
inflammatory  spasmodic  or  cicatricial  strictures,  foreign  bodies, 
tumors,  and  diverticula.  ("2)  Pressure  obstructions  located  with- 
out the  esophagus,  especially  tumors  involving  the  thyroid  body, 
tracheal  and  mediastinal  glands,  or  aneurysms  of  the  arch  of  the 
aorta.  Abscess  from  Pott's  disease  may  also  be  the  cause  of  pres- 
sure obstruction. 

It  is  to  a  variety  of  the  first  group  that  I  wish  to  call  your  at- 
tention at  this  time. 

Etiology  and  General  Character 

Cicatricial  stenosis  of  the  esophagus  is  the  result  of  the  healing 
of  an  ulceration.  The  latter  is  produced  by  a  traumatism,  such 
as  the  swallowing  of  caustic  alkali,  acids,  or  hot  fluids;  occasionally 
by  a  wound,  or  it  may  be  due  to  the  prolonged  lodgment  of  a 

*  Presented  to  the  Section  on  Surgery  and  Anatomy  at  the  Fiftieth  Annual 
Meeting  of  the  American  Medical  Association,  held  at  Columbus,  Ohio,  June  6-9, 
1899.     Reprinted  from  "Jour.  Amer.  Med.  Assoc.,"  July  ^9.  1899. 

11 


12  WILLIAM  J.  :mayo 

foreign  body.  The  most  common  cause,  especially  in  children, 
is  the  accidental  swallowing  of  concentrated  lye. 

Carbolic  acid,  ammonia,  etc.,  are  frequently  taken  by  adults, 
and  the  immediate  mortality  from  the  poisonous  effects  reduces 
to  a  small  proportion  the  number  who  might  hve  to  develop 
cicatrix. 

The  breaking  down  of  a  syphilitic  gumma  may  leave  an  ulcera- 
tion; cases  of  stricture  having  their  origin  in  this  manner  have 
been  reported  by  LubHnski.  Senn  says  that  syphilis  may  cause  a 
fibrous  stricture  of  any  portion  of  the  alimentary  canal,  and  states 
that  it  is  not  ulcerative  in  character. 

Tuberculous  ulceration  of  the  esophagus  is  usually  secondary  to 
swallowing  infected  sputum.  Flexner  reports  19  and  Cone  28  cases 
of  this  variety.  None  of  the  ulcers  in  these  cases  healed  sufficiently 
to  cause  stricture.  Primary  tuberculosis  of  the  gullet  is  very  rare; 
however,  it  occurs  and  may  be  the  cause  of  stenosis.  Zenker  re- 
ports such  a  case.  Poncet  cites  a  case  of  obstruction  due  to  the 
ulceration  attending  actinomycosis;  no  attempt  at  healing  was 
noted,  the  interference  being  mechanical.  Fibrous  strictures  of 
the  esophagus  without  ulceration  have  been  variously  described  as 
idiopathic,  syphilitic,  gouty,  rheumatic,  or  due  to  chronic  esopha- 
gitis.  Audry  records  two  such  cases  supposed  to  be  cancerous, 
which,  after  death,  was  sho"WTi  to  be  due  to  hyperplasia  of  the 
muscular  coat.  Ingals  reports  scA^eral  cases  occurring  in  one 
family.  Rumpel  cited  a  case  of  fusiform  dilatation  of  the  esopha- 
gus, due,  as  he  believed,  to  a  spasmodic  contraction  of  the  thick- 
ened muscular  coat  at  the  lower  end  of  the  gullet  and  collected  20 
cases  from  medical  literature. 

The  pathologic  condition  found  in  the  reported  cases  of  this 
description  shows  a  remarkable  resemblance  to  the  large  fibrous 
stricture  of  the  pylorus,  and  to  that  form  of  fibrous  stricture  of  the 
rectum,  the  etiology  of  which  has  been  the  subject  of  controversy 
for  years.  It  is  probable  that  these  strictures  of  the  alimentary 
canal  have  a  common  origin,  and  for  convenience  fibrous  strictures 
of  the  gullet  are  classed  with  the  cicatricial  form. 

Simple  strictures  of  the  esophagus,  of  unknown  origin,  are  not 


CICATRICIAL    STUICTLRE    OF    THK    KSOI'H A(;LS  1 '{ 

uncommon,  Kendall  Frank  records  a  imiiiher  of  this  variety. 
Ewald  states  that  the  simple  or  j)C|)tic  ulcer  may  be  the  cause  of 
stenosis  and  cites  cases;  it  is  possible  that  this  is  the  etiolofjy  of 
many  of  the. so-called  "simple  strictures."  Congenital  strictures 
are  described  at  length  by  Carey,  with  a  report  of  cases  from  the 
literature  of  the  subject. 

As  the  treatment  of  the  simple  and  congenital  forms  is  essen- 
tially the  same  as  that  of  the  variety  under  discussion,  they  are 
included  in  the  same  class.  The  locations  of  strictures  of  the 
gullet  for  anatomic  reasons  are  most  common  in  three  localities: 

(1)  At  the  isthmus  of  the  esophagus  opposite  the  cricoid  cartilage; 

(2)  at  or  near  the  bifurcation  of  the  trachea,  where  the  gullet  is 
crossed  by  the  left  bronchus;  (3)  at  the  diaphragmatic  opening. 
According  to  the  researches  of  von  Hacker,  this  latter  locality  is 
mo.st  commonly  affected  by  caustics. 

In  the  adult  the  gullet  is  from  nine  to  ten  inches  in  length,  and 
Richardson  has  shown  that  from  the  incisor  teeth  to  the  dia- 
phragmatic opening  it  is  about  143^  inches,  measurements  which 
aid  the  exact  location  by  the  sound.  If  the  stricture  can  be 
passed  by  an  olive  bougie,  Tillman  advises  that  the  tip  be  inserted 
well  beyond  the  stenosis;  on  withdrawing,  the  handle  is  marked 
as  resistance  begins  and  again  as  it  passes  through  the  stricture. 
The  distance  can  thus  be  easily  estimated.  Not  infrequently 
several  strictures  are  found,  or  the  whole  of  the  esophagus  may  be 
obliterated,  as  in  cases  reported  by  Richardson  and  also  by  von 
Hacker. 

Diagnosis 

The  diagnosis  of  the  obstruction  is  easj-;  in  fact,  advanced 
mechanical  stricture  gives  a  group  of  symptoms  which  are  self- 
evident;  of  these,  dysphagia  and  regurgitation  of  food  are  most 
prominent,  and  if  the  obstruction  lies  in  the  cervical  portion,  dys- 
phonia  and  dyspnea  can  be  observed.  Sounding  with  suitable 
bougies  completes  the  diagnosis. 

In  children  with  advanced  cicatricial  stenosis  the  emaciation, 
the  anxious,  hungry  expression,  the  constant  desire  for  liquids  and 
rapid  regurgitation,  form  a  clinical  picture  which  hardly  needs  a 


14  WILLIAM   J.    AL^YO 

question.  In  adults  the  diflFerentiation  as  to  the  nature  of  the 
stenosis  may  be  more  difficult. 

Spasmodic  stricture  is  not  rare,  and  usually  occurs  in  people  of 
a  hysteric  tendency.  According  to  Moullin,  slight  traumatisms 
are  frequently  the  exciting  cause  of  the  hysteric  form,  and  the 
injury  may  be  grossly  exaggerated  by  the  patient.  The  lack 
of  sufficient  cause,  the  suddenness  of  the  onset,  and  the  neurotic 
history  will  usually  suffice  to  clear  up  the  diagnosis,  yet  cases  are 
recorded  by  Pepper  and  others  in  which  it  was  necessary  to  resort 
to  sounding  under  anesthesia  positively  to  exclude  organic  stric- 
ture. 

Esophageal  diverticula  may  cause  difficulty  in  diagnosis.  The 
origin  of  these  pouches  is  stated  by  Maylard  to  be:  (1)  Congenital ; 
(2)  the  result  of  a  strictured  condition  below;  (3)  from  pressure 
or  traction.  These  diverticula  are  most  common  on  the  posterior 
wall,  about  on  a  level  with  the  cricoid  cartilage.  Error  in  sound- 
ing is  thus  liable  to  occur,  the  bougie  passing  into  the  pocket.  The 
possibility  of  such  occurrence  will  put  one  on  guard  and  prevent 
serious  difficulty  in  differentiation. 

Butlin  has  collected  a  number  of  cases  from  the  London  hos- 
pital reports,  many  of  which  have  been  diagnosed  as  stricture. 
Malignant  strictures  and  pressure  tumors  suggest  at  once  clinical 
phenomena  which  will  render  exclusion  easy. 

Esophagoscopy  cannot  be  considered  an  important  aid  to  diag- 
nosis. Von  Hacker,  in  Billroth's  clinic,  used  a  Leiter  panelectric 
light  \^dth  small  benefit,  and  while  numerous  devices  have  been 
developed  since,  not  much  evidence  of  value  has  accumulated. 
Stoerk  describes  a  new  esophagoscope,  but  its  usefulness  seems 
uncertain.  Einhorn  is  one  of  the  few  authorities  who  place  re- 
liance upon  this  clinical  method  in  diagnosis. 

Prognosis 

The  prognosis  of  untreated  cicatricial  stenosis  is  bad — there 
is  a  constant  tendency  to  contract,  indeed,  there  seems  to  be  no 
limit  to  this  process. 

The  esophagus  gradually  dilates  above  the  stricture;  its  muscu- 


CICATRICIAL   STUK  TLUK   OF   THE    ESOPHAGUS  15 

lar  cojit  hyporlropliics,  and,  \>y  ii  scjuccziiij^  process,  some  nourisJi- 
ment  is  forced  through  the  stenosed  porli<jii  until  a  hito  date,  the 
starvation  hcinf,'  a  very  slow  process.  In  time  fatty  degeneration  of 
tlie  muscle-fiber  renders  the  esophagus  unetjual  to  its  task,  and  also 
makes  instrumentation  exceedingly  dangerous.  Many  deaths  have 
been  reported  by  Sands  and  others  from  instrumental  perforation. 
A  casual  examination  of  the  literature  of  the  subject  leads  one  to 
tiiink  that  this  is  not  an  uncommon  accident  in  attemj)ts  at  sound- 
ing in  late  cases.  Weinlechner  describes  an  island-like  stricture 
which  may  prevent  the  passage  of  solid  food  and  yet  not  cause 
complete  obstruction  to  a  fluid  diet  for  an  indefinite  time.  I 
have  observed  such  a  case. 

Case  1. — Strichire  of  Esophagus  I jn permeable  to  Bougie — 
Comfortable  Existence  for  Years  on  a  Fluid  Diet. — Mrs.  P.  McK., 
aged  thirty-six  years,  the  mother  of  a  large  family,  in  August, 
1891,  gave  a  history  of  having  swallowed  caustic  lye  when  a 
child;  since  that  time  she  has  lived  on  a  fluid  diet,  being  able  to 
swallow  only  strained  lic^uid  food.  She  has  frequent  attacks  of 
regurgitation  lasting  several  days  at  a  time,  and  thinks  that  on 
an  average  one-third  of  the  food  is  regurgitated.  At  times  she 
gets  very  thin. 

She  is  a  badly  nourished  woman,  of  slender  build  and  anemic 
ajipearance.  Careful  sounding  reveals  a  dense  stricture  near 
the  cardiac  end  of  the  esophagus.  Above  the  stricture  the  esoph- 
agus is  dilated  to  a  considerable  extent.  Repeated  examination 
failed  to  pass  the  stricture.  The  patient  refused  any  operative 
interference,  and  has  passed  from  observation. 

Treatment 
The  treatment  of  traumatism  of  the  esophagus  at  an  early 
period,  before  contraction  takes  place,  is  of  the  utmost  imj)ortance. 
In  this  way  many  of  the  imfortunate  results  can  be  avoided  or 
rendered  manageable.  After  the  swallowing  of  a  caustic  sub- 
stance systematic  sounding  should  be  commenced  in  from  two  to 
four  weeks  (Meyer).  Foreign  bodies  should  not  be  allowed  to  re- 
main in  tlie  esophagus  until  ulceration  is  produced,  and  prolonged 
attempts  at  removal  through  the  mouth  cannot  be  considered 


16  WILLIAM   J.    MAYO 

good  surgery.  Gerster  directs  attention  to  the  ease  with  which 
foreign  bodies  can  be  removed  through  an  external  esophagotomy 
if  done  early,  before  ulceration  has  taken  place;  in  this  way 
C.  H.  Mayo  has,  on  five  occasions,  readily  removed  foreign  bodies 
from  the  lower  part  of  the  esophagus.  The  x-ray  is  of  great  value 
in  locating  many  of  these  bodies,  and  a  right  incision  in  the  neck 
instead  of  the  ordinary  left  may  be  indicated,  as  in  a  case  of  an 
impacted  overshoe  buckle  in  which  the  loop  to  the  right  and  the 
sharp  prongs  to  the  left  decided  the  question. 

In  the  lower  esophagus  the  method  of  Richardson — removal 
through  an  incision  in  the  stomach-wall — is  of  the  greatest  value, 
and  must  rank  as  one  of  the  achievements  of  modern  surgery. 
Tillman  strongly  advocates  preliminary  gastrostomy  for  feeding 
purposes  in  the  primary  stages  of  acute  ulceration,  thereby  lessen- 
ing the  infection  and  hastening  cure.  In  tuberculous  and  syphi- 
litic ulceration  appropriate  constitutional  treatment  should  be 
used  in  conjunction  with  the  sounding  during  the  period  of  cica- 
trization. 

Dilatable  Strictures 

Gradual  dilatation  is  the  method  of  choice  in  this  form  of 
stenosis.  The  larger  and  softer  the  dilator  the  better,  but  in 
many  advanced  cases  such  instruments  are  wholly  worthless.  In 
these  cases  the  use  of  whalebone  olive-tipped  probes  are  best  for 
the  smaller  varieties,  and  for  the  larger  bougies  a  whalebone  stem 
to  which  increasing  sizes  of  metal  or  ivory  olive  tips  can  be  at- 
tached are  the  most  valuable.  If  the  tip  is  made  very  long  and 
tapering,  it  will  engage  in  the  stenosed  portion  more  quickly  than 
the  ordinary  olive  tip,  which  expands  so  rapidly  that  one  cannot 
easily  appreciate  whether  or  not  it  is  engaged  in  the  stricture. 

In  a  previous  paper  on  this  subject,  read  before  the  Minnesota 
Academy  of  Medicine  in  March,  1894,  I  exhibited  what  I  then 
believed  to  be  a  new  probe,  in  which  three  or  four  increasing  sizes 
of  bulbs  were  made  on  a  single  stem  (Trousseau's),  the  idea  being 
that  the  small  tip  would  railroad  the  others  through.  As  a  matter 
of  fact,  it  prevented  that  elasticity  within  a  few  inches  of  the  tip, 


ClCArUKIAI.    STUKTIHK    OK    TlIK    i:s(  )1MI  A(;  t  S 


1 


wliicli  is  ii  priiiK*  cssciilial  in  a  j^'ood  \)(>\\'/n\  ciial)!!!!;^  one  to  pass 
through  the  curved  i)haryiix  without  injuriously  impinging  on  the 
posterior  wall.  This  elasticity  is  necessary,  as  it  also  permits  some 
j)lay  at  the  point  and  facilitates  search  oi"  the  lace  of  the  stricture 
for  the  opening. 


Fig.  2  — Showing  manner  of  introducing  the  silk  cord  with  the  rubber  drainage-tube  looped  in  position 

ready  for  introduction. 


Fig.  3. — Showing  the  manner  In  which  the  tube  is  drawn  out  in  order  to  pass  through  a  tight  stricture 


Many  cases  appear  to  be  impermeable  to  the  probe,  which  in 
time  may  be  safely  passed.  The  frightened  little  sufferer  adds  to 
the  general  discomfort  and  renders  a  hasty  judgment  in  this  regard 
only  too  natural.  I  once  heard  an  eminent  genito-urinary  surgeon 
say  that  impermeable  strictures  of  the  urethra  hai)pened  largely 

VOL.  I — i 


18  WILLIAM   J.    MAYO 

in  an  early  experience,  and  I  am  sure  that  this  is  true  of  esophageal 
stricture.  With  care  and  gentleness  a  bougie  can  usually  be  in- 
serted in  the  opening,  although  several  sittings  may  be  required. 
In  such  cases  a  number  of  whalebone  bougies  lubricated  with 
glycerin  should  be  passed  into  the  gullet  and  against  the  stricture 
in  the  same  manner  as  filiforms  are  used  in  the  urethra,  and  by 


Fig.  4. — Showing  a  double  rubber  drainage-tube,  looped  into  one  already  drawn  through.     As  many 
tubes  as  may  be  necessary  to  obtain  the  desired  dilatation  may  be  drawn  through  in  this  way. 


alternating  probes  one  will  usually  slip  through.  It  is  best  to 
stop  here,  and  then  every  other  day  repeat  the  process,  using  per- 
haps several  increasing  sizes  at  one  sitting;  the  first  probe  intro- 
duced should  have  a  very  flexible  handle,  and  when  in  place, 
straightens  the  throat  curve  so  that  the  larger  and  stiffer  bougies 
readily  follow,  each  one  being  left  in  the  stricture  until  the  next 


CKATHKIAL    STHirTlIfK    OK    TlIK    KSOI'lIAGUft  19 

one  is  ready  by  its  side.  In  ji  few  eases  it  may  be  neecssary  to 
use  an  anestlietie  the  first  time  or  two,  but  usually  the  patient  will 
sit  on  a  low  stool  lacing  the  operator,  and  i'roni  tlic  relief  ;ilford<'(l 
by  the  ability  to  retain  a  little  nourishmeni,  will  soon  face  the 
ordeal  with  an  unexijeeled  degree  of  fortitude.  The  fretjueney  of 
sounding  depends  on  the  case,  every  other  day  being  sufficient,  and 
in  sen.sitive  patients  perhaps  too  frecpient.  Many  months  are  oc- 
eujned  in  this  gradual  dilatation,  and  after  ai)j)arent  cure  a  sound 
should  l)e  passed  occasionally  for  years. 

Case  2, — Sfricfure  of  EsoplHu/iis:  flnuliial  Dilafdtioti:  Re- 
covery.— T.  C,  a  male,  aged  two  years,  was  admitted  to  St.  Mary's 
Hospital  February  24,  1898,  with  a  history  of  having  accidentally 
swallowed  concentrated  lye  seven  weeks  ])reviously.  Difficulty 
in  swallowing  developed  at  once.  At  first  this  was  due  to  trau- 
matism and  resulting  ulceration,  later  to  the  contraction. 

At  no  time  since  the  injury  has  solid  food  been  taken,  and 
a  large  part  of  liquid  nourishment  swallowed  is  regurgitated. 
Before  admission  to  the  hospital  several  attempts  at  sounding 
the  esophagus  had  been  made,  but  without  success. 

On  examination  a  stricture  was  detected  in  the  thoracic  esoph- 
agus. Under  anesthesia  several  whalebone  bougies  were  placed 
in  position,  and  by  using  first  one  and  then  another,  a  probe  was 
finally  ])assed  into  the  stomach.  The  stricture  dilated  easily, 
and  a  fair-sized  bougie  was  introduced  at  this  time.  Systematic 
sounding  every  third  day  was  carried  out,  and  March  8,  1898,  the 
little  i)atient  was  discharged,  able  to  take  liquids  easily,  and 
chopped  meat  and  softened  bread  with  but  little  difficulty.  Since 
that  time  soundings  have  been  made  at  intervals,  the  esophagus 
being  of  nearly  normal  caliber. 

Non-dilatable  Strictures 

Stenosis  involving  a  large  extent  of  the  esophagus  may  jirevent 
gradual  dilatation  or  even  continue  to  contract  while  attempts  at 
dilatation  are  being  carried  out,  and  in  a  few  cases  the  difficulties 
and  dangers  attending  the  sounding  of  a  tight  stricture  make  a 
resort  to  some  more  rapid  method  desirable. 

For  strictures  in  the  vicinity  of  the  cricoid  cartilage  external 
e.sophagotomy  after  Billroth  is  the  ojjcration  of  choice.     Like  the 


20  WILLIAM   J.    MAYO 

perineal  cut  for  stricture  of  the  urethra,  funnel-shaped  retraction 
of  the  cut  portion  is  caused  by  adhesion  to  the  external  tissues 
divided,  and  it  lessens  future  contraction.  This  operation,  first 
performed  by  Mitchel  and  later  by  Annandale,  has  stood  the  test, 
and  should  not  be  long  delayed.  A  most  interesting  case  of  this 
kind  is  recorded  by  Fenger.  Frank  has  successfully  performed 
esophagectomy  in  a  case  of  simple  stricture  in  this  portion  of  the 
esophagus,  the  divided  ends  being  sutured  over  a  tube  passed 
through  the  nose. 

For  dense  stricture  above  the  arch  of  the  aorta  and  below  the 
point  which  can  be  directly  divided,  Gussenbauer's  combined 
esophagotomy  is  the  best  operation:  through  an  external  incision 
in  the  neck  a  tenotome  is  introduced  and  passed  downward  to  the 
stricture,  which  is  then  di\aded. 

I  take  the  liberty  to  introduce  an  illustrative  case  previously 
reported : 

Case  3. — Tico  Strictures  of  Esophagus;  Prolonged  Dilatation 
and  Combined  Esophagotomy;  Recovery. — J.  H.,  aged  four  years, 
was  seen  in  January,  1893.  In  the  spring  of  1892,  while 
living  in  North  Dakota,  the  child  swallowed  concentrated  lye. 
After  a  month's  severe  illness  he  gradually  recovered,  but  ^dth 
an  increasing  difficulty  in  swallowing.  During  the  past  three 
months  all  food  has  to  be  strained  and  he  has  frequent  attacks  of 
regurgitation.  The  material  regurgitated  is  brought  up  somewhat 
slowly.  He  is  a  moderately  well-nourished  boy,  of  good  disposi- 
tion, which  materially  aided  treatment.  On  the  introduction  of  a 
catheter  it  was  arrested  at  the  isthmus  of  the  gullet.  After  some 
manipulation  a  No.  3  urethral  catheter  was  passed  three  inches 
farther  doTvnward,  where  it  was  completely  arrested. 

It  was  very  evident  that  there  was  a  stricture  at  the  level  of 
the  cricoid  cartilage,  and  a  second  in  the  intrathoracic  portion  of 
the  esophagus,  undoubtedly  produced  by  the  action  of  the  esoph- 
ageal muscles  at  the  time  of  the  original  accident,  causing  the 
effect  of  the  lye  to  be  located  at  these  points. 

Regular  sounding  was  instituted,  and  continued  at  intervals 
of  three  to  ten  days,  with  but  slight  interruption  for  one  year. 
At  the  end  of  two  months  the  lowest  stricture  was  passed  by  a 
fine  whalebone  bougie.  This  stricture  was  very  dense,  and  re- 
sisted sounding  obstinately;    it  was  only  at  intervals  of  several 


nr'ATHKIAI.    STUKTT'UE    OF    THK    ESOPIIAfa'S    •  21 

sittings  tliat  tiic  hoiigic  could  he  iiit  roducc*!  into  I  lie  stom;ich.  At 
the  ('11(1  of  a  year's  perscvcranct;  llie  upiKT  stricture  had  yielded 
to  the  extent  of  admitting  a  No.  5  catheter  and  the  lower  one  a 
No.  .'{.  The  l)oy  was  well  nourished,  did  not  re^'urj^'itate  unless  he 
took  solid  food,  and  was  ahle  to  take  softened  hread  and  finely 
chopped  meat.  During  the  preceding  two  months  no  perceptible 
improvement  was  manifest;  therefore  on  PY'hruary  15,  1804,  he 
was  admitted  to  St.  Mary's  Hospital,  and  on  February  IGth  left 
external  esophaj^otomy  was  performed.  The  ni)[)er  stricture  was 
now  readily  dilated  })y  forceps.  'J'he  hjwer  stricture,  which  wa.s 
below  the  level  of  the  uj)per  end  of  the  sternum,  wa.s  carefully 
nicked  with  a  dull  knife  on  a  fjrooved  director  and  dilated  with 
forceps,  j)ermittin<,'  of  easy  catheterization  of  the  esopha^Mis. 

Unfortunately,  the  majority  of  dense  strictures  are  in  the  lower 
esophagus,  or  if  there  is  one  stricture  in  the  upper  portion,  another 
will  usually  be  found  lower  down.  In  three  cases  in  the  experience 
of  the  writer  more  than  one  stricture  was  present,  but  the  lower 
in  each  instance  was  the  more  dense. 

How  to  reach  strictures  situated  below  the  arch  of  the  aorta  in 
the  thoracic  esophagus  by  direct  means  has  been,  and  is  yet,  a 
problem.  NasollofT,  Quenu,  and  Hartmann  developed  an  opera- 
tion for  external  eso])hagotomy  on  the  cadaver,  which  Rehn  first 
l)cri'ormcd  on  the  living  subject,  an  incision  from  the  fourth  to  the 
eighth  rib  on  the  right  side  of  the  spinal  column  being  employed. 

The  difficulties  and  dangers  of  this  plan  of  attack  are  so  great 
that  indirect  measures  are  to  be  relied  u[)on. 

For  this  purpose  two  methods  are  available — Abbe's  string- 
saw  and  Ochsner's  operation;  in  the  latter  a  loop  of  rubber  tubing 
is  used  as  a  dilating  medium.  The  one  method  supplements  the 
other.  Division  of  the  stricture  by  the  string-saw  invented  by 
Abbe  has  l)een  jjcrformed  a  number  of  times  with  great  success. 

Through  a  gastrotomy  wound  a  stout  silk  cord  is  passed  in  a 
retrograde  way  through  the  esoi)hagus  and  out  through  the  mouth 
or  through  an  external  esophagotomy.  The  stricture  is  made 
tense  by  engaging  bougies  into  it  from  below,  and  by  a  sawing 
motion  of  the  cord  the  tight  bands  are  divided,  while  the  important 
soft  parts  are  crowded  back  out  of  the  way.     After  full  dilatation 


22  WILLIAM   J.    MAYO 

has  been  secured  the  incisions  can  be  closed,  or  a  rubber  tube  is 
inserted  to  a  point  above  the  stricture  and  brought  out  of  the 
gastric  incision,  the  latter  being  united  to  the  margins  of  the  ab- 
dominal wound.  In  two  or  three  days  the  tube  is  removed  and 
sounding  from  above  employed  in  the  usual  manner. 

Case  4. — Stricture  of  Esophagus;  Division  and  Dilatation 
after  Gastrotomy  and  External  Esophagotomy;  Testimony  as  to 
the  Value  of  Abbe's  String  Method  of  Division. — H.  W.,  aged  three 
years,  was  admitted  to  St.  Mary's  Hospital  on  October  5,  1892, 
with  the  folloT\dng  history,  given  by  her  mother: 

One  year  previously  the  child  accidentally  swallowed  caustic 
lye.  For  four  weeks  she  was  very  sick,  then  gradually  improved 
for  several  months,  although  totally  unable  to  swallow  soHd  food 
at  any  time.  During  the  last  six  months  she  has  had  great  diffi- 
culty in  swallowing  liquids,  and  has  regurgitated  from  the  esoph- 
agus more  than  half  of  the  nourishment  taken. 

She  is  emaciated  to  a  considerable  degree.  Upon  being  given 
two  oimces  of  milk  it  was  drunk  with  avidity,  but  was  nearly 
all  regurgitated.  The  dilated  esophagus  above  the  stricture 
holds  nearly  four  ounces  of  fluids.  Bougies  were  inserted  through 
the  pharynx  into  the  esophagus,  but  were  completely  arrested 
at  its  lower  end,  while  careful  search  of  the  face  of  the  stricture 
with  a  number  of  whalebone  bougies,  under  anesthesia,  failed  to 
pass  the  stenosed  portion.  At  intervals  of  four  days  this  search 
was  continued,  but  without  result.  While  undergoing  these 
repeated  examinations  the  child  became  much  better  and  was 
able  to  retain  a  larger  proportion  of  liquid  nourishment,  and 
improved  visibly. 

Proper  manipulation  was  much  interfered  -^dth  by  the  short, 
sharp  curve  of  the  child's  pharynx  and  its  small  size;  therefore 
external  esophagotomy  was  urged  upon  the  parents  to  permit 
of  more  direct  access  to  the  parts  involved.  This  was  decUned, 
and  the  little  girl  was  taken  home  at  the  end  of  two  weeks. 

On  July  19,  1893,  the  child  was  readmitted  to  the  hospital. 
The  slight  improvement  had  been  of  short  duration,  a  gradual 
closing  of  the  small  channel  had  taken  place,  and  for  the  past 
four  weeks  it  had  been  nearly,  if  not  quite,  impermeable,  so  that 
the  little  patient  had  been  nourished  by  rectal  enemata. 

As  before,  careful  search  failed  to  pass  the  stricture.  External 
esophagotomy  with  a  hope  of  finding  a  way  through  the  damaged 
esophagus  did  not  promise  the  rapid  relief  that  the  child's  nutri- 


ricATKKiAL  sTRinrHr:  of  tiik  kscjimiaol's  23 

lion  tleniaiuled;  tluM-clorc  on  July  'iO,  IBO.'J,  a  ^'astroslomy  was 
made  alter  the  iiietliod  ot"  lH'iij,'('r,  tlu"  incisitjii  l)eirifi  made  us 
lii^^li  lip  and  as  close  to  the  median  line  as  jxjssihle,  to  permit  of 
ret  ro^radc  dilatation. 

Fen^^er's  oj)eration  was  chosen,  as  permitting  more  direct  and 
easy  access  to  the  cardiac  orifice  ot"  the  stomach,  in  place  of  the 
von  Hacker  or  Witzel  methods,  which  are  far  superior  as  a  means 
of  preventing  leakage  from  the  fistula,  but  also  present  greater 
obstruction  to  intraj^'astric  manipulation.  The  child  was  now  well 
nourisiied  through  the  gastric  fistula,  and  twice  a  week  the  lower 
face  of  the  stricture,  which  was  at  the  diaphragmatic  opening, 
was  carefully  searched  for  an  outlet.  On  two  occasions  the  finger 
was  introduced  through  the  fistula  into  the  stomach  and  used  as 
a  guide  for  the  i)robe,  the  patient  being  anesthetized.  The  dila- 
tation of  the  fistula  necessary  to  introduce  the  finger  in  so  small 
a  subject  greatly  increased  the  leakage  through  the  gastric  open- 
ing, and  the  child  again  began  to  fail,  from  the  inability  of  the 
stoiiiach  to  retain  nourishment. 

On  August  25,  1893,  a  left  external  esophagotomy,  at  a  low 
point  in  the  neck,  was  performed  by  C.  H.  Mayo,  and  a  bougie 
introduced  through  this  opening  and  pressed  against  the  stricture, 
pushing  it  downward  into  the  stomach  and  holding  it  steadily. 
With  a  finger  in  the  stomach  a  long  malleable  German-silver  probe 
was  passed  through  the  stricture  and  out  of  the  esophageal  fistula 
in  the  neck,  A  heavy  double  strand  of  braided  silk  was  drawn 
through  the  channel,  having  an  end  out  of  the  opening  in  the 
esophagus  and  also  out  of  the  gastric  fistula.  The  stricture  was 
about  three  quarters  of  an  inch  in  length,  as  nearly  as  could  be 
ascertained.  Using  one  strand  to  cut  the  tissues,  after  the  method 
recommended  by  Robert  Abbe,  knots  were  tied  on  the  second 
strand  and  pulled  into  the  obstruction  to  keep  the  stricture  tense, 
and  the  opening  was  greatly  enlarged.  This  method  was  of  the 
greatest  value,  and  had  but  one  disadvantage — that  of  cutting 
the  edge  of  the  gastric  fistula  when  drawn  taut,  which  was 
in  part  obviated  by  holding  the  lower  end  of  the  cutting  thread  in 
the  bite  forceps,  held  on  a  j)lane  with  the  stricture  from  within  the 
stomach.  Knots  on  the  second  thread,  to  render  the  stricture  tense, 
were  equally  good  and  easier  of  execution  than  pushing  bougies 
from  below  into  the  small  opening,  as  recommended  by  Abbe. 

During  the  succeeding  month,  at  intervals  of  four  days,  this 
process  of  division  was  carried  on,  and  perforated  shot  clamped 
upon  the  thread  were  drawn  through  to  assist  in  the  dilatation, 
iis   they   readily   followed   the   tortuous   passage.     Bougies   then 


24  WILLIAM   J.    MAYO 

became  permissible,  inserted  first  from  the  neck  and  later  through 
the  mouth. 

In  five  weeks  the  threads  were  removed  and  dilatation  was 
carried  on  with  olive-tipped  whalebone  bougies  made  for  the 
purpose.  A  sister  of  the  little  patient  was  taught  to  pass  the 
probe,  and  the  child  was  discharged  from  the  hospital  in  two 
months  in  a  good  general  condition;  able  to  drink  milk  readily 
and  to  take  chopped  meat  and  bread  with  little  effort.  The 
esophageal  fistula  had  spontaneously  closed,  and  the  gastric  open- 
ing, after  being  touched  with  the  cautery,  was  nearly  cicatrized. 
March  19,  1899,  the  patient  is  well. 

The  following  operation  was  first  successfully  performed  by 
Ochsner  in  February,  1899.  In  April,  1899, 1  had  an  opportunity 
to  employ  this  method,  with  satisfactory  results.  The  technic  is  as 
follows:  The  anterior  wall  of  the  stomach  is  dra\\^  out  of  a  left 
oblique  incision  through  the  abdominal  coverings ;  a  small  opening 
is  made  into  the  stomach  sufficient  in  size  to  introduce  the  finger. 
A  whalebone  probe,  to  the  tip  of  which  a  silk  string  guide  has 
been  tied,  is  now  passed  through  the  esophagus  either  from  above 
or  retrograde,  as  in  the  Abbe  method.  With  this  guide  a  loop  of 
silk  is  drawn  out  of  the  gastric  incision  in  such  manner  as  to  leave 
the  guide  as  a  third  string.  Into  this  loop  a  small  soft-rubber 
drainage-tube,  three  feet  or  more  in  length,  is  caught  in  the  middle; 
by  traction  on  the  ends  of  the  doubled  thread  through  the  mouth 
this  loop  of  rubber  tube  is  drawn  through  the  stomach  and  made  to 
engage  in  the  stricture. 

The  greater  the  amount  of  traction,  the  smaller  the  stretched 
rubber  tube,  until  it  is  sufficiently  reduced  in  size  to  enter  the 
stenosed  portion;  by  alternating  the  direction  of  the  pull  the  tube 
is  drawn  out  by  its  free  ends  and  in  by  the  silk  loop.  Increasing 
sizes  of  tubes  can  be  employed,  and,  if  necessary,  the  third  string 
can  be  used  as  a  string  saw  after  the  Abbe  plan  of  procedure. 

Case  5. — Stricture  of  the  Esophagus;  Gastrostomy  and  Dilatation 
by  Ochsner's  Method;  Recovery. — G.  H.,  female,  aged  nine  years, 
was  admitted  to  St.  Mary's  Hospital  March  3,  1899,  with  the 
following  history:   Four  months  before  she  accidentally  swallowed 


CICATUICIAL   STUICTL'llE    OF    TlIK    K.SOI'HA(a:.S  '2.'} 

coMcoiif  nitcd  lye.  Tlic  iilccriilioii  |)ro(luc('(l  was  slow  in  Iicaliii^', 
and  tlicdifliculty  in  swallowiii^f  ^M-adiially  Ix'caiiK'  iiion"  proiKjiiiifcjl. 
For  the  past  month  only  htpiid  has  l)('en  attcnij)t('<l,  and  the 
greater  part. has  at  once  been  regurgitated.  Emaciation  was 
extreme.  On  examination  a  stricture  in  the  h>wer  esophagus  was 
readily  detected  by  a  bougie.  After  considerable  effort  a  fine 
whalebone  probe  was  j)assed.  There  apjjcared  to  be  two  points 
of  contraction,  about  an  inch  apart,  the  lower  being  at  the  dia- 
l)hragniatic  opening.  Systematic  probing  during  the  next  seven 
weeks  did  not  yield  nnich  result;  occasionally  a  larger  probe  could 
be  passed,  and  again  only  the  finest  could  be  used.  During  this 
time  rectal  feeding  was  employed  to  supplement  the  very  limited 
nourishment  obtained  by  means  of  the  esophagus.  The  little  pa- 
tient became  so  much  reduced  that  on  April  20,  1899,  the  abdomen 
was  opened  by  a  left  oblicjue  incision.  A  fine  probe  armed  with 
a  silk  thread  was  passed  through  the  eso})hagus  into  the  stomach. 
The  thread  was  caught  and  drawn  out  of  the  incision;  by  this 
means  two  threads  of  heavy  silk  were  drawn  upward  and  the 
silk  guide  left  in  position. 

A  quarter-inch  rubber  drainage-tube  was  lubricated  and  caught 
l)y  the  middle  in  the  loop;  by  traction  from  above  the  tube  was 
drawn  through  the  stomach  and  into  the  eso])hagus,  considerable 
traction  being  required  to  engage  it  in  the  strictured  area.  By 
first  using  traction  U])ward  on  the  strings  and  then  downward 
on  the  free  ends  of  the  tube  the  stricture  was  rapidly  dilated. 
The  dilating  tube  was  removed,  and  a  half-inch  rubber  tube  was 
introduced  into  the  gastric  opening,  and  through  this  tube  the 
three  threads  were  drawn,  the  free  ends  being  tied  to  the  ends 
projecting  from  the  mouth. 

A  gastric  fistula  was  then  formed  after  the  method  of  Bernays, 
the  rubber  tube  being  inclosed  by  three  superimposed  circular 
purse-string  sutures  of  catgut,  one-fourth  of  an  inch  apart,  intro- 
duced in  the  wall  of  the  stomach  around  the  incision,  the  margin 
of  the  fistula  being  then  sutured  to  the  abdominal  woimd.  This 
causes  a  cone  or  nipple-like  lu'ojection  of  the  wall  into  the  lumen 
of  the  stomach,  and  through  this  tu])e  sufficient  nourishment  was 
introduced.  The  general  condition  im])r()ved  ra])idly  and  sys- 
tematic sounding  was  carried  on  as  before,  with  increasing  sizes 
of  bougies. 

Internal  esophagotomy,  first  performed  by  Maisonneuve  in  1861 , 
has  since  been  made  about  'io  times  (Richardson),  with  a  death-rale 


26  WILLIAM   J,    IVIAYO 

of  over  25  per  cent.  Above  the  arch  of  the  aorta  the  operation  is 
unnecessary;  below  it  is  a  "chance  shot"  and  success  a  lucky  acci- 
dent. Konig  believes  that  permanent  gastrostomy  is  preferable. 
Sands'  instrument  shares  with  ISIackenzie's  the  doubtful  honor  of 
being  best  for  the  purpose.  Meyer,  in  an  interesting  summing  up 
of  internal  instrumental  esophagotomy,  says  that  the  danger  of 
accidental  injury  to  important  structures  is  not  greater  than  the 
introduction  of  infective  material  without  the  gullet,  such  infec- 
tions being  responsible  for  more  than  hah  the  mortality.  He 
recommends  gastrostomy  for  the  purpose  of  feeding  and  also  to 
allow  preliminary  cleansing  of  the  operative  field,  if  internal 
instrumental  esophagotomy  is  adopted.  Internal  divulsion  is 
nearly  as  dangerous  as  the  cutting  operation  and  less  effective. 
Fletcher's  esophageal  di\Tilsor  has  been  used  a  few  times.  Mixter 
has  devoted  a  great  deal  of  attention  to  this  subject.  He  recom- 
mends that  Symonds'  tube,  as  originally  advocated  for  malignant 
strictures,  be  introduced,  and  believes  that  that  steady  pressure 
will  gradually  increase  the  caliber.  It  would  seem  that  a  stricture 
of  sufficient  size  to  permit  of  permanent  tubage  could  be  overcome 
by  gradual  dilatation.  The  literature  of  the  subject  is  filled  with 
cuts  of  more  or  less  ingenious  instruments  for  the  purpose  of  dilat- 
ing these  strictures:  the  spiral  rolled  tin  sounds  of  Rosenheim, 
the  laminaria  tent  of  Senator,  and  a  host  of  others,  interesting  but 
of  questionable  value;  of  these,  linear  electrolysis,  as  introduced 
by  LeFort,  has  had  the  greatest  reputation.  The  marvelous 
nature  of  the  cures  MTOUght  in  many  cases  leads  one  to  believe 
that  the  enthusiastic  advocates  of  electricity  failed  to  exclude  the 
spasmodic  variety  with  sufficient  care. 


Impassable  Strictures 
In  a  moderate  number  of  strictures  a  probe  cannot  be  passed 
through  the  mouth,  yet  after  an  external  esophagotomy  the  bougie 
can  be  manipulated  to  so  much  better  advantage  that  the  opening 
may  be  found,  and,  after  a  few  soundings,  conducted  through  the 
fistula;    the  future  dilatation  is  continued  through  the  mouth. 


CICATRICIAL   STUICTLRIO    OF   TFIK    KSOI'HACL'S  27 

Graser  particularly  advises  this  in  children.  KaiiimcnT  reported 
a  case  before  tlie  New  York  Surgical  Society  in  which,  after  faih'ng 
to  pass  the  stricture  by  retrograde  sounding  through  a  gastric-  in- 
cision, success  followed  probing  from  al)ove  through  an  external 
esopliagotoniy.  Konig  had  a  series  of  fine  siKer  balls  made  and 
threaded;  one  swallowed  at  Ix'dtime  would  usually  pass  the  sten- 
osed  area  during  the  night,  and  was  drawn  back  through  by  the 
thread  in  the  morning.  Zeehei.sen  records  two  cases  in  which  an 
opening  passable  to  a  sound  was  .secured  in  this  manner.  Billroth 
succeeded  in  several  cases  with  a  cylindric  cloth  bougie  partly  filled 
with  mercury,  the  weight  and  adaptability  of  the  metal  carrying 
it  through. 

Ga.strotomy  and  retrograde  dilatation  were  recommended  by 
Schede  in  1883,  and  first  performed  by  Trendelenburg.  Frank 
collected  20  cases  cured  in  this  manner.  Since  that  time  a  large 
number  of  successful  cases  have  been  recorded.  Great  and  unex- 
pected difficulty  is  often  experienced  in  attempting  retrograde  dila- 
tation through  a  gastric  fistula.  It  is  a  surprising  fact  that  under 
such  circumstances  it  may  be  almost  impossible  to  find  the  car- 
diac opening.  For  this  reason  the  dilatation  should  be  carried 
out  as  the  primary  operation  if  possible.  Richardson  directs  that 
the  anterior  wall  of  the  stomach  be  delivered  and  a  small  transverse 
incision  made  into  its  cavity  near  the  lesser  curvature,  in  the  neigh- 
borhood of  the  pylorus;  by  traction  on  the  stomach  just  below  this 
incision  the  lesser  curvature  forms  a  sulcus  along  which  the  instru- 
ments glide  into  the  cardiac  orifice. 

Hagenback  turned  defeat  into  triumph  in  a  case  in  which  he 
was  unable  to  find  the  stricture  from  below,  and  made  a  gastric 
fistula  for  feeding  purposes.  He  caused  the  patient  to  swallow  a 
small  perforated  .shot  to  which  a  thread  was  attached;  this  passed 
through  the  stricture  and  was  hooked  out  of  the  fistula,  acting  as  a 
guide  for  future  manipulation. 

Abbe  recommends  that  a  string  guide  be  introduced  by  which 
dilating  bougies  can  be  drawn  upward  retrograde,  and  that  this 
guide  should  be  retained  in  place  until  a  sound  can  be  introduced 
from  above.     Observation  has  shown  that  it  is  possible  to  pass  an 


28  AVILLIAM   J.    MAYO 

instrument  retrograde  when  impassable  from  above,  but  that  regu- 
lar dilatation  from  below  without  a  guide  may  prove  very  difficult. 

Twenty-eight  cases  from  the  literature  of  retrograde  dilatation 
are  analyzed  by  George  Woolsey,  and  the  comparative  merits  of 
the  various  methods  of  cutting  are  clearly  stated. 

It  may  happen  that  the  condition  of  the  patient  will  not  permit 
prolonged  attempts  at  retrograde  dilatation,  and  a  rapid  gastros- 
tomy should  be  done  by  the  Witzel  or  the  multiple  purse-string 
method  of  Bernays,  as  either  permits  immediate  feeding,  does  not 
leak,  and  yet  can  be  readily  converted  into  a  direct  opening  by  a 
dilator  when  needed  for  later  attempts  at  retrograde  dilatation. 
With  the  improvement  in  nutrition  which  follows  gastrostomy 
and  the  absolute  rest  to  the  esophagus,  in  a  short  time  a  probe 
may  be  passed  from  above. 

Case  6. — Cicatricial  Stenosis  of  the  Esophagus;  Gastrostomy; 
Gradual  Dilatation  Through  the  Mouth.— V.  M.,  aged  three  years, 
was  admitted  to  St.  Mary's  Hospital  July  1,  1894.  Nine  months 
previous  to  admission  the  little  fellow  had  accidentally  swallowed 
concentrated  lye.  Symptoms  of  esophageal  obstruction  becoming 
more  and  more  pronounced,  attempts  were  made  to  dilate  the 
strictured  gullet  without  success.  At  first  solids  were  regurgi- 
tated, later  fluids,  and  for  six  weeks  nourishment  had  been  main- 
tained by  rectal  feeding. 

The  child  is  emaciated  to  an  extreme  degree,  and  is  too  feeble 
to  stand.  Fluids  are  eagerly  swallowed,  only  to  be  regurgitated 
at  once.  Attempts  to  pass  whalebone  probes  through  the  stricture 
were  unavailing.  Gastrostomy  after  the  Witzel  method  was  per- 
formed and  immediate  feeding  resorted  to. 

Regular  feeding  through  the  gastric  fistula  soon  improved  the 
patient's  general  condition.  Systematic  search  for  an  opening 
through  the  stricture  from  above  was  made  every  other  day  for 
several  weeks  before  a  small  whalebone  probe  passed.  After 
this  success  the  bougie  failed  to  find  the  orifice  a  second  time  for 
a  number  of  days.  Three  months  of  persistent  effort  finally 
developed  a  moderately  sure  passage.  For  five  months  all  the 
feeding  was  carried  on  by  the  gastric  fistula,  a  good-sized  opening 
through  the  stricture  having  developed  by  this  time. 

On  February  22,  1895,  the  patient  was  discharged,  being  able 
to  eat  ordinary  food,  and  since  that  time  he  had  been  regularly 


firATRICIAL    STRICTURE    OF    Till-:    ESOPHAGUS  '20 

sounded  and  had  ri'iiiaiucd  in  cxccllcnl  licaltli  until  June,  18!)H, 
wlien  he  was  reachnitted  to  the  hospital  with  coinj^lete  obstruction, 
hiivin^  three  (hi\'s  l>efore  aceidentally  swallowed  a  mass  of  ehewing- 
<,'urn  which  had  ti<i;htl\'  wedj^cd  in  the  ojienin^';  this  was  removed 
with  some  difficulty. 

Durin<;  the  four  years  which  had  ehipscd  the  same  bougies 
were  contimied  l)y  his  j)arents  without  taking  into  account  the 
growth  of  the  child. 

Proper  sized  probes  were  obtained,  and  lie  iia>  since  remained 
in  good  condition. 

There  will  yet  remain  a  few  cases  in  which  a  large  part  of  the 
esophagus  is  obliterated,  and  permanent  gastrcstomy  after  the 
Frank  method  is  the  melancholy  outcome. 

In  summing  up,  the  following  conclusions  may  be  formulated: 

1.  Systematic  sounding  should  be  commenced  in  from  two  to 
four  weeks  after  the  swallowing  of  a  caustic  substance. 

2.  Should  the  traumatism  be  severe,  immediate  gastrostomy 
will  lessen  infection  and  hasten  cicatrization,  sounding  being 
carried  on  as  before. 

3.  Non-dilatable  strictures  in  the  vicinity  of  the  cricoid  carti- 
lage should  be  divided  by  external  esophagotomy. 

4.  Stricture  above  the  arch  of  the  aorta  may  be  safely  cut  by  a 
combined  internal  and  external  esophagotomy. 

5.  Dense  thoracic  strictures  are  best  dilated  by  Ochsner's 
method,  and,  if  necessary,  divided  by  Abbe's  string  saw. 

6.  Impassable  strictures  should  be  treated  by  retrograde  dila- 
tation. 

7.  A  dilated  stricture  should  be  occasionally  sounded  for  years, 
if  not  for  life. 


1 


STOMACH 


i 


SURGERY  OF  THP:  STOMACH* 

WILLIAM    J.    MAYO 


The  stomach  is  now  amenable  to  surgical  relief  from  a  number 
of  conditions  which  until  recently  have  been  supposed  to  be  purely 
medical  in  character.  In  many  instances  the  stomach  offers  un- 
expected opportunities  for  operative  interference.  First,  it  is  an 
organ  more  or  less  fixed  within  a  certain  definite  part  of  the  upper 
abdomen.  Second,  in  a  large  majority  of  instances  it  can  be  irri- 
gated and  rendered  fairly  clean  before  operation.  Third,  bj'  rectal 
alimentation  it  can  be  given  rest  after  operation.  Fourth,  its 
thick  muscular  walls  afford  a  good  hold  for  sutures,  while  its  blood- 
supply  is  of  a  nature  to  favor  union  after  extensive  resections, 
herein  differing  materially  from  the  thin-walled  intestine,  nourished 
by  the  mesentery,  with  more  or  less  constant  vermicular  action. 

The  cardiac  extremity  of  the  stomach  is  the  only  fixed  point, 
and  it  is  suspended,  so  to  speak,  in  a  way  to  vary  its  position, 
whether  contracted  or  dilated — in  the  former  case  lying  deep  under 
the  liver  against  the  crura  of  the  diaphragm,  and  in  the  latter 
occupying  a  prominent  position  in  the  hypogastrium.  The  lesser 
omentum,  containing  the  main  blood-vessels,  is  of  great  surgical 
importance,  as  are  also  the  relations  of  the  mesocolon  and  other 
delicate  structures  in  the  neighborhood  of  the  pylorus.  As 
pointed  out  by  Tillaux,  the  cartilage  of  the  ninth  rib  forms  an 
important  guide  to  the  lower  border  of  the  stomach. 

The  diagnosis  of  gastric  disease,  as  a  rule,  is  not  difficult.  The 
stomach  can  be  distended  by  ether,  as  recommended  by  Felitzet, 
or  by  the  use  of  bicarbonate  of  soda  and  an  acid,  as  practised  by 
Jacobi.     Usually,  tiic  introduction  of  a  definite  ([uantity  of  water 

*  Reprinted  from  tlie  "Medical  Record,"  XovemlH-r  10.  181)4.  pp.  ,'>S(>-.>S^. 
VOL.  1—3  33 


34  WILLIAM   J.    MAYO 

will  sufficiently  mark  its  outline,  and,  by  forcing  air  into  the  colon 
per  rectum,  as  practised  by  Senn,  the  relation  of  the  stomach  to 
the  transverse  colon  can  be  mapped  out.  By  such  means  I  was 
able  to  diagnose  a  pancreatic  cyst,  the  tumor  being  shown  to  be 
retroperitoneal  and  lying  behind  the  gastrocoHc  omentum.  The 
operation  proved  the  diagnosis. 

The  value  of  the  examination  of  test -meals  and  the  amount 
of  acid  as  affecting  the  diagnosis  of  cancer  as  pointed  out  by 
von  Jaksch  in  his  "Clinical  Diagnosis,"  the  presence  of  free 
hydrochloric  acid  being  a  factor  in  the  diagnosis  as  against  cancer 
and  in  favor  of  ulcer.  The  effect  of  the  weight  of  tumors  in  dis- 
placing the  stomach  is  ably  shown  by  Osier  in  a  series  of  papers, 
beginning  in  the  "New  York  Medical  Journal"  of  February  3, 
1894.  As  preliminary  to  operation  upon  the  stomach,  irrigation 
is  of  great  value  where  it  can  be  practised,  and,  as  pointed  out  by 
Kussmaul,  much  benefit  may  be  derived  from  lavage  where  ob- 
struction exists  below,  thus  relieving  the  stomach  of  irritating 
material,  removing  the  distention  and  interference  with  breathing, 
and  putting  the  patient  into  better  condition  for  operation.  Shall 
the  stomach  be  distended  previous  to  operation,  to  facilitate  its 
discovery.''  Distention  may  assist  in  finding  the  stomach,  but  it 
complicates  the  further  manipulation  and  introduces  an  element 
of  danger  of  wound  contamination  from  escape  of  its  dilating  con- 
tents. 

The  after-treatment  of  gastric  operations  is  changing  toward 
the  earlier  administration  of  food  by  the  stomach,  especially  in 
exhausted  patients,  although  rectal  feeding  is  the  rule  during  the 
first  few  days. 

Before  closing  these  general  considerations  the  writer  wishes 
to  call  attention  to  gastric  distress  produced  by  traction  of  ad- 
herent omentum.  Billroth  has  written  upon  this  subject,  es- 
pecially in  reference  to  the  small  "buttons"  of  omentum  protrud- 
ing through  little  gaps  in  the  upper  abdominal  wall.  Konig  re- 
ports some  20  cases  operated  upon.  We  have  observed  two  cases 
of  this  description:  Case  1,  a  boy  of  fifteen,  with  a  small  hernia 
of  adherent  omentum  protruding  through  a  little  defect  in  the 


SURGKI{Y    (M"    Till-:    STOMACH  .S.> 

nuMlian  line  ahovc  the  iiinl)ilicus.  Case  ^2,  a  woman  of  filly,  with 
adherent  oinenluni  in  a  femoral  hernia.  Neither  of  the  patients 
had  any  local  symptoms  at  the  site  of  the  protrusion,  and  both 
were  relieved  ll)y  operation.  We  have  also  observed  cases  of  this 
form  of  omental  adhesion  with  corresponding];  symptoms  in  ef)n- 
nection  with  post-operative  ventral  hernias. 

Wounds  and  injuries  of  the  stomach  are  to  be  treated  on  sur- 
gical principles,  and  where  evidence  of  perforative  wounds  are 
found,  operative  repair  is  imi)erative.  Rose  speaks  of  persistent 
vomiting  of  blood  as  a  reliable  sign  of  gastric  injury.  In  case  there 
is  injury  to  the  head  at  the  same  time,  the  possibility  of  blood 
having  been  swallowed  from  the  upper  passages  should  be  borne 
in  mind. 

Foreign  bodies  in  the  stomach  are  a  not  infrequent  cause  of 
danger  and  suffering,  and  gastrotomy  for  the  purpose  of  their 
removal  has  been  greatly  perfected.  Richardson  gives  a  careful 
analysis  of  reported  cases,  and  makes  many  valuable  modifica- 
tions in  the  technic,  when  the  foreign  body  lies  in  the  lower  esopha- 
gus. Bull  also  reports  excellent  work  in  this  direction.  The  value 
of  a  potato  diet  in  the  non-operative  treatment  of  foreign  bodies  of 
the  alimentary  canal  should  not  be  forgotten. 

Fistulas  are,  as  a  rule,  the  result  of  operative  technic,  and 
rarely  come  from  accidental  or  pathologic  causes.  They  vary 
greatly  in  the  difficulty  of  repair  on  account  of  location,  those 
adjacent  to  the  bony  framework  being  more  dijQBcult  of  operation 
than  those  more  remote.  The  value  of  the  provisional  suture  to 
prevent  escape  of  stomach-contents  during  manipulation  is  ap- 
parent. 

Chronic  dilatation  of  the  stomach,  when  not  due  to  organic 
lesion,  may  be  caused  by  chronic  gastric  catarrh  with  sagging  of 
the  fundus,  rendering  evacuation  difficult.  Taylor  has  studied  this 
condition  carefully,  and  believes  that  it  produces  a  kinking  at  the 
pylorus,  with  prominence  of  the  mucous  fold,  causing  a  bar-like 
obstruction  to  theemptying  of  the  stomach.  He  practises  oi)era- 
tive  dilatation  of  the  pylorus  with  success.  Bircher,  followed  by 
WVir,  raises  the  fundus  mechanically  and  reduces  its  size  by  putting 


36  WILLIAM   J.    RIAYO 

a  longitudinal  plait  along  the  walls,  turning  a  fold  into  its  cavity. 
This  operation  is  indicated  in  cases  where  lavage  has  for  a  time 
failed  to  relieve  the  symptoms. 

Ulcer. — In  the  diagnosis  of  ulcer,  the  age  of  the  patient,  the 
quantity  of  the  vomit,  the  lack  of  emaciation,  which  in  ulcer  is 
more  often  a  profound  anemia  mthout  great  loss  of  flesh,  the 
presence  of  free  acid,  and  the  slow  course  of  the  disease  are  all 
valuable  symptoms  of  ulceration  as  against  carcinoma.  Opera- 
tion may  be  demanded  for  acute  perforation,  provided  it  can  be 
diagnosed  in  time.  As  can  be  readily  perceived,  the  location  of 
the  perforation,  whether  on  the  anterior  or  on  the  posterior  wall, 
will  greatly  influence  the  ease  of  repair.  Ulcer  of  the  stomach 
being  most  frequent  on  the  posterior  wall,  a  perforation  may  oc- 
casionally take  place,  and  the  escaping  material,  on  account  of  its 
mechanical  surroundings,  become  encapsulated  as  a  subdiaphrag- 
matic abscess.  Weir  points  out  the  frequency  of  left  pneumo- 
thorax due  to  the  secondary  results  of  perforative  ulcer.  The 
following  is  a  report  of  a  case  of  subdiaphragmatic  abscess  (No. 
1537,  St.  Mary's  Hospital  Record) : 

Scandinavian,  fifty  years  of  age,  with  history  of  chronic  stomach 
trouble,  became  suddenly  ill,  developed  pain,  and,  later,  cough 
and  hiccup.  A  deep  swelling  became  manifest  in  the  sixth  inter- 
space, just  to  the  right  of  the  sternum,  for  relief  of  which  he  entered 
the  hospital.  A  deep  incision  was  made  and  pus  evacuated; 
but  as  a  sinus  formed  and  failed  to  heal,  the  cartilages  of  the  sixth 
and  seventh  ribs  and  a  large  portion  of  the  lower  end  of  the  sternum 
were  resected.  The  sinus  was  followed  through  the  diaphragm 
to  the  neighborhood  of  the  lesser  omentum,  where  a  small  cavity 
existed;   this  was  packed  \\'ith  gauze  and  slow  healing  followed. 

The  secondary  results  of  ulcer  in  producing  contraction  at  the 
pylorus  may  call  for  operation  for  obstruction — either  the  digital 
divulsion  of  Loreta  or,  better,  the  Heineke-Mikulicz  pyloroplasty. 
Weir  reports  a  case  of  this  character  in  which  gastro-enterostomy 
was  performed,  and  in  selected  cases  advocates  its  expediency. 

Cancer  of  the  Stomach. — The  age  of  the  patient,  lack  of  free 
acid  in  the  vomit,  the  emaciation,  and  the  possible  presence  of 


SURCEKY    OK    TIIK    S|()MA(  II  .'37 

pt'plont's  ;iii<l  alhiiiniu  in  llic  urine  aid  in  llie  diu^iKjsis  ol  ( iiiiccr. 
(lU.ssenl)uuer  and  Winiwarter  ^ivc  (50  per  cent,  us  the  proportion 
of  pylorie  cancer  lo  llic  whole  number,  liull,  with  slatislics  of 
1300  cases  of  <;astric  cancer,  <;ives  the  proportion  as  aljove  .50 
per  cent,  in  the  i)yl<)rus.  liuth'n  says  of  these  cases  that  a  very 
hirge  nunil)er  of  j)atients  with  pyloric  cancer  die  from  obstruction 
before  glandular  infection  or  extensive  adhesion  takes  place. 
Billroth  says  that  cancer  of  the  pylorus  produces  great  muscular 
hypertroj)hy,  and  death  from  obstruction  results  in  one-half  of 
the  cases  before  adhesions  or  glandular  infection  supervene.  It 
is  i)robable,  therefore,  that  j)ylorectomy  and  ])artial  gastrectomy 
have  a  larger  field  than  has  been  sui)posed,  although  IJutlin,  in  a 
careful  analysis  of  reported  cases  subjected  to  operation,  takes  a 
very  gloomy  view  of  the  situation.  In  cases  of  cancer  involving 
the  cardiac  orifice,  gastrostomy  is  advocated  by  von  Hacker  for 
the  j)urpose  of  feeding.  Lauenstein  has  been  impressed  by  certain 
unfortunate  .sequelae  of  gastrostomy  in  these  cases,  such  as  con- 
stant leakage,  involvement  of  the  fistula,  etc.  However,  with 
either  the  AVitzel  or  the  Frank  operation  of  gastrostomy  this  ob- 
jection would  not  hold  good.  For  cancer  of  the  fundus  of  the 
stomach  Bernays  practises  ga'strotomy  and  cureting  of  the  mass 
from  within  the  stomach.  He  shows  that  in  the  majority  of 
cases  the  growth  of  the  cancer  is  toward  its  free  cavity. 

In  this  connection  an  allusion  to  the  remarkable  disappearance 
or  temporary  checking  of  the  growth  of  tumors  after  simple  ex- 
|)loratory  incision  would  not  be  out  of  j)lace.  Tait  first  called 
attention  to  this  phenomenon.  White  has  extensively  investi- 
gated this  subject  in  regard  to  the  curative  value  of  operations 
of  themselves,  independent  of  their  intention.  The  total  disap- 
pearance of  a  cancer  after  simple  abdominal  incision  must  neces- 
sarily be  rare,  but  I  have  observed  temjjorary  checking  of  its 
progress  after  laparotomy  in  several  instances.  In  laparotomy 
for  cancer  of  the  stomach  a  varicose  condition  of  the  peritoneal 
veins  overlying  the  growth  is  frequently  observed,  and  is  due  to 
obstructed  internal  circulation  leading  to  .adhesions.  In  124 
ojierations  on  the  stomach  and  intestines  Billroth  gives  a  mortality 
of  .50  per  cent. 


38  WILLL\M   J.    MAYO 

Operations  on  the  Sto:\l\ch. — In  gastric  operations  the  ab- 
dominal incision  selected  for  most  purposes  will  be  that  of  Fenger. 
This  is  made  parallel  to  the  left  costal  cartilages,  and,  unless  other- 
wise ^ecified,  is  the  one  used,  except  for  fistula  and  other  con- 
ditions where  there  is  no  choice  of  locality.  Gastrorrhaphy,  a 
method  due  to  the  genius  of  Billroth,  may  be  performed  for  wounds 
and  injuries,  the  simple  Lembert  or  a  Czerny-Lembert  suture  being 
applied.  For  fistulas,  some  special  means  must  be  used  of  pre- 
venting escape  of  the  stomach-contents  during  operation.  The 
older  method  was  to  introduce  a  sponge  with  attached  string,  and 
hold  this  firmly  against  the  opening.  The  provisional  suture  of 
the  margins  of  the  fistula  is  a  much  better  practice,  and  in  many 
cases,  by  trimming  away  the  attached  tissues  afterward,  can  be 
left  as  a  Czerny  suture  and  the  Lembert  applied  to  roll  it  in;  or 
the  stomach  being  brought  out,  the  whole  of  the  fistula  may  be 
excised  and  the  Czerny-Lembert  suture  applied.  In  1891  Bircher 
invented  his  operation  for  simple  dilatation  of  the  stomach  by 
suturing  a  fold  which  projects  into  its  lumen  ^^dth  a  Lembert  su- 
ture.    Weir  has  practised  this  'vvith  marked  success. 

Gastrotomy  for  Foreign  Bodies. — In  1886  Richardson  recom- 
mended a  large  gastric  incision  and  the  introduction  of  the  whole 
hand,  if  necessary,  to  remove  bodies  from  the  lower  esophagus. 
Bull  recommends  a  small  gastric  incision,  and,  with  fingers  intro- 
duced, invaginates  the  wall  into  the  stomach  ca\aty.  In  either 
case  several  holding  sutures  with  which  to  manipulate  the  stomach 
are  better  than  the  fingers  or  forceps,  which  may  shp  and  injure 
the  vitality  of  the  wound  margins.  Gastrotomy  for  the  purpose  of 
cureting  cancerous  growths  has  been  performed  by  Bernays,  but 
cannot  be  commended. 

Gastrotomy  for  Dilatation. — In  1892  Loreta  practised  gastrotomy 
for  the  purpose  of  obtaining  digital  diAiilsion  of  the  pylorus  for  ob- 
struction. This  operation  may  be  performed  for  stenosis  of  either 
orifice  of  the  stomach.  Taylor  has  made  gastrotomy  several  times 
for  the  purpose  of  obtaining  digital  dilatation  of  the  pylorus  in  cases 
of  twisting  at  the  neck  of  the  stomach  due  to  chronic  dilatation, 
and    reports    successful    cases.     Heineke    and    Mikulicz,    almost 


SURGERY    OF   THE    STOMAf  H  30 

simultaneously,  perforiueci  pyloroplasty  ior  cicatricial  stenosis  of 
the  pylorus.  In  the  procedure  as  ordinarily  performed  a  gastrot- 
oiny  is  first  made,  and  a  grooved  director  introduced  through  the 
stricture  from  tlie  stomach:  the  contracted  tissues  are  then  divided 
hy  a  longitudinal  c-ut,  and  this  incision  is  united  in  a  transverse 
direction  by  suture.  This  admirable  operation  has  been  per- 
formed by  Senn  and  many  other  surgeons,  with  good  results. 

Gastrostomy  for  the  purpose  of  feeding  is  indicated  by  any  ob- 
struction between  the  mouth  and  the  stomach,  if  it  cannot  be 
relieved  by  less  dangerous  and  more  expedient  methods.  The 
operation,  as  first  performed  l)y  Sedillot  in  1840,  had  a  perilous 
existence.  In  recent  years  the  method  known  as  Fenger's  has 
usually  been  employed,  but  its  high  mortality,  the  leakage,  with 
attendant  loss  of  nutrition  and  irritation  of  the  surrounding  skin, 
made  it  a  procedure  rarely  resorted  to.  In  preventing  this  leakage 
Ferrier  made  the  important  suggestion  that  the  gastric  opening  be 
made  high  up  near  the  lesser  curvature.  Most  operations  up  to 
this  time  were  done  in  two  stages,  the  stomach  being  first  sutured 
to  the  abdominal  incision  and  the  site  of  the  future  fistula  marked 
by  ligatures,  to  guide  the  opening  after  adhesions  had  taken  place. 
In  a  case  of  impermeable  cicatricial  esophageal  stricture  I  was 
compelled  to  make  a  gastrostomy  after  this  method  for  the  pur- 
pose of  feeding  and  for  retrograde  dilatation  and  division  after 
Abbe's  string  method.  While  the  eventual  recovery  was  good, 
the  annoyance  of  the  constant  leakage  was  great.  Hahn  modified 
this  operation  by  making  the  opening  in  the  stomach  high  up,  and 
putting  the  fistula  between  the  ril)s  for  better  mechanical  closure. 
This  is  done  by  making  an  abdominal  incision  and  locating  the 
stomach;  a  special  short  incision  in  the  eighth  intercostal  space  is 
then  made,  and  by  passing  forceps  through  this  buttonhole,  they 
can  be  applied  to  the  proper  place  on  the  stomach-wall  by  the 
fingers  in  the  large  incision,  and  the  stomach  fixed  in  the  small 
opening,  after  whicli  the  abdominal  incision  is  closed.  For  retro- 
grade dilatation  of  the  esopliagus  von  Hacker's  method  should  be 
preferred,  as,  while  it  affords  only  a  moderate  degree  of  retention. 


40  WILLIAM   J.    MAYO 

It  permits  excellent  intragastric  manipulation.  The  method  con- 
sists of  a  perpendicular  incision  through  the  body  of  the  rectus 
muscle,  which  gives  somewhat  of  a  sphincter  action.  Witzel's 
method  is  the  best  for  temporary  fistula,  as  it  gives  perfect  closure 
against  leakage.  After  the  usual  incision  the  stomach  is  drawn 
well  out  and  a  small  cut  made  in  its  wall,  through  which  a  rubber 
tube  the  size  of  a  lead-pencil  is  introduced  one  inch  toward  the 
fundus.  With  a  Lembert  suture  the  free  walls  of  the  stomach  are 
drawn  together  over  the  tube,  beginning  one  inch  to  the  left  and 
continuing  to  the  right  one  and  one-half  inches,  forming  a  channel 
lined  with  peritoneum.  The  stomach  is  dropped  back  and  sutured 
to  the  incision.  The  great  advantages  of  this  operation  are  that 
feeding  may  be  commenced  at  once  without  any  danger  of  leakage, 
and,  on  withdrawal  of  the  tube,  the  peritoneal  granulation  tissue 
lining  the  channel  will  heal  permanently.  This  is  of  obvious  advan- 
tage if  the  condition  giving  rise  to  the  operation  can  be  removed. 
Andrews  has  modified  this  operation  by  free  incision  of  the  stom- 
ach and  formation  of  a  channel  from  the  mucous  membrane. 
This  is  done  to  avoid  the  use  of  a  permanent  tube,  but  is  difficult 
to  perform,  and  gives  greater  danger  of  infection.  For  permanent 
gastric  fistula  the  method  advocated  by  Frank  is  undoubtedly  the 
best.  In  this  procedure  a  fold  of  the  stomach  one  and  one-half 
inches  long  is  drawn  out  and  sutured  to  the  parietal  peritoneum  at 
its  base.  The  skin  above  the  upper  margin  of  the  abdominal  in- 
cision is  undermined  along  the  seventh  rib  to  a  point  over  the  sixth 
rib,  where  an  incision  three-fourths  of  an  inch  in  length  is  made. 
The  stomach-cone  is  carried  under  the  skin-flap,  the  apex  sutured 
to  the  buttonhole,  and  the  abdominal  incision  is  then  closed,  giving 
a  spout-like  opening.  This  operation  is  a  model  one  for  the  purpose 
of  securing  a  permanent  fistula.  Great  credit  is  due  to  Willy 
Meyer  for  the  popularization  of  the  Witzel  and  Frank  opera- 
tions in  this  country. 

ResectioJis  of  the  Stomach. — It  was  due  to  the  courageous  work 
of  Billroth  and  Wolfler  and  Czerny,  in  the  face  of  an  appalling  mor- 
tality, which  made  resection  of  the  stomach  a  legitimate  operation. 


SLKCEKY    Ol"    THE    STO.MAC  H  41 

Pean,  in  1870,  ina<l('  llic  first  pylorccloiiiy,  tlioii^li  imsuccessfully. 
The  mortality  ol"  Billrotli,  the  greal  exijonent  of  j)ylorectoniy,  has 
been  nearly  .50  per  cent.,  deaths  being  due  largely  to  collapse,  and 
a  number  to  gangrene  of  the  colon  from  injury  to  the  mesocolon 
while  separating  the  pylorus.  This  surgeon  employs  the  trans- 
verse abdominal  incision,  resects  the  stomach  in  a  V  shape,  using 
a  close  Czerny-Lembert  suture  in  closing  the  gastric  incision,  and 
suturing  the  end  of  the  duodenum  into  the  lower  angle  of  the 
stomach  wound.  The  separation  of  the  pylorus  is  very  carefully 
done,  and  just  sufficient  of  the  greater  and  lesser  omentum  tied 
off  to  permit  of  operation.  The  greatest  care  of  the  mesocolon 
must  be  taken.  The  tendencj'  of  American  and  English  surgeons, 
led  by  Bull,  McCormick,  Treves,  and  Greig  Smith,  is  to  make  the 
usual  median  abdominal  incision,  and  suture  the  stomach  with 
the  Czerny-Lembert  suture.  The  pylorus  is  now^  cut  away  from 
the  duodenum,  and  the  end  of  the  latter  sutured,  gastro-enteros- 
tomy  being  then  performed.  This  carries  the  opening  away  from 
the  dangerous  suture  line.  Partial  gastrectomy,  as  a  rule,  is  a 
simpler  operation,  Maydl  having  once  removed  nearly  one-half 
of  the  organ.  Complete  gastrectomy  has  been  attempted  several 
times,  notably  by  Conner,  but  must  necessarily  fail  on  account  of 
total  destruction  of  the  mesocolon.  Ohage,  in  the  midst  of  a 
partial  gastrectomy,  was  confronted  by  unsuspected  difficulties 
which  rendered  removal  impossible.  The  stomach  was  freely 
opened  above,  the  malignant  mass  turned  into  its  cavity,  and  the 
upper  cut  edge  sutured  to  the  wall  below  the  growth.  The  patient 
not  only  lived,  but  for  two  years  has  been  practically  well.  Gas- 
tro-enterostomy  is  indicated  by  obstruction  of  the  pylorus,  es- 
pecially if  this  be  malignant  and  not  suited  for  pylorectomy.  It 
was  first  performed  by  Wolfler  in  1881,  with  suture,  and  up  to  the 
time  of  Senn's  innovation  in  the  use  of  bone  plates  for  anasto- 
mosis the  mortality  was  great — about  50  per  cent.  Postnikow 
lias  attempted  to  improve  the  suture  operation  by  freely  incising 
the  structures  of  the  stomach  and  gut  to  the  mucous  coat,  which  is 
ligated,  and  then  suturing  the  corresponding  parts  together,  in  the 


42  WILLIAM   J.    MAYO 

expectation  that  adhesions  will  take  place  before  sloughing  of  the 
mucous  coat  completes  the  fistula.  In  all  these  operations,  if  the 
duodenum  cannot  be  easily  drawn  to  the  stomach,  a  loop  of  the 
jejunum  may  be  used  and  drawn  around  the  omentum,  which  is 
pushed  to  the  left,  rather  than  through  its  folds.  The  latter 
practice  has  in  several  instances  caused  death  from  kinking  of  the 
intestine  and  obstruction. 


SOME  MECHANICAL  CAUSES  OF  INTERFER- 
ENCE WITH  THE  ACTION  OF  THE 
STOMACH  AND  THEIR  SUR- 
GICAL RELIEF* 

WILLIAM    J.    MAYO 


Mechanical  interference  with  the  action  of  tlie  stomach  natu- 
rally divides  itself  into  two  classes:  First,  factors  which  act  from 
within  the  cavity,  as  a  tumor,  cicatrix,  or  a  foreign  body  which 
may  obstruct  its  inlet  or  outlet,  or  prevent  its  normal  muscular 
action;  second,  factors  which  act  from  without  the  stomach,  and 
interfere  either  by  pressure  or  by  adhesions,  obstructing  its  inlet 
or  outlet  or  fixing  some  portion  of  its  wall,  thus  preventing  func- 
tion. 

Methods  of  Diagnosis. — For  practical  purposes  the  history,  the 
physical  examination,  the  distention  with  air,  and  the  test-meal 
constitute  our  main  diagnostic  resources.  A  careful  history  in- 
cludes the  early  symptoms, — pain,  tumor,  or  swelling,  vomiting, 
with  the  character  of  the  vomitus,  and  such  other  evidences  as 
suggest  themselves.  The  distention  of  the  stomach  with  air 
to  facilitate  mapping  out  its  outline  is  an  exceedingly  important 
factor  in  the  diagnosis.  With  an  ordinary  stomach-tuiie  and  a 
valve  syringe  air  can  be  easily  and  safely  pumped  into  the  stom- 
ach, and  it  escapes  readily  upon  disconnecting  the  syringe.  The 
test-meal  is  of  importance  in  the  diagnosis  of  cancer.  Experience 
has  shown  that  the  presence  or  absence  of  free  hydrochloric  acid 
is  of  some  service  in  the  differentiation  of  chronic  obstruction,  with 
the  physical  examination    and  history,  although  of  itself  it   has 

*Read  in  the  Section  on  Surgery  and  Anatomy,  at  the  forty-seventh  annual 
mcotinp  of  the  American  Medical  Association  at  Atlanta,  Ga.,  >Iay  5  to  8.  1S9G. 
llopriiitetl  from  "Jour.  Amer.  Med.  .Vssoc.,"  Juse,  lS9(i. 

43 


44  WILLIAM   J.    MAYO 

corroborative  value  only.  Many  new  methods  of  examining  the 
stomach  have  been  reported.  The  use  of  a  small  electric  light  to 
illuminate  the  gastric  cavity;  also  complicated  apparatus  for  the 
purpose  of  reflecting  or  measuring  the  interior  of  the  stomach, 
etc.  These  methods  are  of  little  value  to  the  practical  surgeon  at 
the  present  time,  although  they  may  possibly  be  of  use  in  the 
future.  The  examination  of  the  urine  for  the  finding  of  certain 
products  supposed  to  be  indicative  of  cancer  is  interesting,  rather 
than  important. 

Mechanical  obstructions  of  the  cardiac  orifice  of  the  stomach 
or  the  esophagus  are  most  commonly  due  to  malignant  disease  or 
the  cicatrization  following  upon  the  action  of  caustics;  more  rarely 
to  aneurysms  or  tumor  pressure  from  without.  The  diagnosis  of 
the  location  of  the  obstruction  by  means  of  esophageal  bougies  is 
easy  and  needs  no  comment,  while  the  history  and  rational  signs 
and  symptoms  point  to  the  pathologic  nature  of  the  obstruction. 

The  treatment  of  those  forms  due  to  stenosis  as  a  result  of 
scar  tissue  is  exceedingly  trying.  Some  of  the  less  resistant  cases, 
when  seen  early,  can  be  dilated  by  means  of  bougies  used  through 
the  mouth,  but,  after  failure  of  catheterization  in  the  usual  man- 
ner, the  opportunity  of  more  direct  manipulations  afforded  by 
external  esophagotomy  has  been  pointed  out  by  Sonnenberg,  and 
should  be  borne  in  mind.  In  two  out  of  three  cases  of  cicatricial 
stenosis  of  the  esophagus  of  my  own  this  was  well  illustrated — one, 
a  male  aged  four,  in  whom  a  probe  could  not  be  passed  through  the 
mouth,  but  was  passed  through  the  external  esophageal  incision. 
If  unable  to  pass  a  bougie,  retrograde  dilatation  by  means  of  gas- 
trotomy  is  a  rational  procedure,  and  with  the  string  method  of 
dividing  the  stricture  introduced  by  Abbe,  we  were  enabled  to 
deal  with  otherwise  hopeless  conditions  in  two  cases.  In  the 
gradual  dilatation  which  is  so  necessary  in  the  successful  after- 
care of  these  sufferers  I  have  found  the  olive-tipped  whalebone 
bougies  the  ones  of  most  value,  and  after  the  treatment  is  well 
advanced,  the  use  of  probes  having  several  graduated  bulbs  on 
one  stem,  as  recommended  by  Solis-Cohen,  is  of  great  service. 

Gastrotomy  for  the  purpose  of  retrograde  dilatation  is,  per- 


MF.cnAMCAI.   CATSES    INTKHI  F.IU  NC    WITH    (iAsTHH     AfTICJ-V       45 

hai)s,  host  done  l)y  FiMi^'er's  ()Mi((iie  left  laterul  incision  tliron^'li 
the  ahdoniinul  wall,  which  l)rin<^s  this  opening  more  directly  in 
line  with  the  cardiac  orifice.  For  work  on  the  pylorus  or  the  re- 
raoval  of  foreign  hodies  or  gastric  exploration  generally,  the  central 
incision  al)o\'c  the  unihilicus  has  many  advantages. 

Gastrotoniy  for  the  removal  of  foreign  hodies  accidentally  or 
purposely  swallowed  or  slowly  collected,  such  as  hair-balls,  is  an 
operation  of  great  efficiency.  Much  credit  is  due  to  Richardson 
for  his  work  in  this  field. 

Gastrostomy  for  the  purpose  of  feeding,  necessitated  by  cardiac 
or  esophageal  obstruction,  when  done  by  Fenger's  method,  is 
subject  to  great  annoyance  in  the  waj^  of  leakage.  This  was 
particularly  marked  in  a  case  under  my  care.  Fortunately  for 
the  comfort  of  the  little  patient,  the  purpose  of  the  opening  was 
shortly  obviated  by  relief  of  the  obstruction.  The  necessity  of 
repeated  attemjits  to  penetrate  the  strictured  portion  of  the  lower 
esoi)hagus,  as  well  as  for  feeding  j)urposes,  made  Fenger's  opera- 
tion, in  this  case,  the  only  one  available. 

Other  methods  of  operation,  while  giving  better  closure,  would 
equally  prevent  I'eady  access  to  the  cardiac  orifice.  Both  the 
Witzel  method  and  that  of  Frank  are  free  from  this  annoyance, 
and  for  temporary  purposes  the  Witzel  method  is  of  the  greatest 
benefit,  as  immediately  after  removing  the  tube  the  fistulous  tract 
closes.  Tliis  was  so  well  marked  in  one  instance  that  the  accidental 
slipping  out  of  the  tube  was  followed  in  a  few  hours  by  great  diffi- 
culty in  reinsertion.  Frank's  sprout  method,  as  it  requires  no  tube, 
is  undoubtedly  the  best  for  permanent  feeding,  and  as  it  is  an  opera- 
tion which  can  be  speedily  performed,  it  is  classed  with  the  Witzel 
and  is  far  superior  to  that  of  Hahn,  von  Hacker,  or  Fenger  in 
preventing  leakage. 

Obstructions  at  the  outlet  of  the  stomach  are  exceedingly 
common,  and  are  too  often  pronounced  malignant  without  proper 
examination.  This  is  especially  true  of  the  pyloric  stenosis  sec- 
ondary to  ulcer,  and  as  even  a  tumor  may  be  found,  in  the  latter 
condition  due  to  the  peritoneal  thickening  over  the  cicatricial  area, 
much  care  should  be  given  in  the  diagnosis  to  determine  the  nature 


46  willia:^!  j.  zsiayo 

of  the  obstruction.  The  history  of  prolonged  previous  ulceration, 
with  the  presence  of  free  hydrochloric  acid,  and  its  slower  course 
are  among  the  readier  means  of  differentiation,  and  it  should  also 
be  borne  in  mind  that  a  non-malignant  pol;sT3oid  or  valve  acting 
tumor  at  the  pyloric  orifice  may  be  the  cause  of  the  obstructive 
symptoms,  as  well  as  a  cancerous  growth.  For  the  rehef  of  non- 
malignant  stricture  at  the  pylorus  Loreta's  method  of  divulsion 
is  open  to  the  objection  of  strong  probability  of  recontraction, 
so  common  in  other  strictured  mucous  passages,  such  as  the 
urethra. 

The  Heineke-Mikulicz  pyloroplastic  operation  is  the  one  of 
choice,  and  is  wonderfully  well  adapted  to  the  average  case.  For 
example,  I  ^"ill  briefly  report  the  following  case : 

M.  M.,  male,  aged  forty-six,  has  suffered  from  severe  and 
painful  gastric  sjTnptoms  for  seven  years,  for  which  he  has  been 
treated  almost  constantly,  obstructive  symptoms  gradually  becom- 
ing more  prominent.  For  the  past  eighteen  months  he  has 
vomited  daily  almost  the  entire  amount  of  food  taken,  and  has 
lost  80  pounds  in  weight.  Just  above  the  umbilicus  a  small  tumor 
could  be  felt,  which  was  more  or  less  movable,  and  on  dilating 
the  stomach  with  air  this  mass  moved  to  the  right  and  upward, 
while  the  air-dilated  stomach  filled  almost  the  whole  abdominal 
ca^aty.  By  making  pressure  on  the  dilated  stomach  and  listening 
with  a  stethoscope  over  the  enlargement,  a  hissing  of  gas  passing 
through  a  fine  orifice  could  be  heard.  Test-meals  showed  the 
stomach-contents  to  contain  free  acid.  Celiotomy  showed,  as 
expected,  a  cicatricial  obstruction  of  the  pylorus  due  to  former 
ulceration.  Pyloroplasty  was  readily  performed,  and  as  the 
patient  took  the  anesthetic  badly,  he  was  allowed  to  come  out 
from  under  its  influence  and  complained  of  no  pain  during  the 
introduction  of  the  Czerny-Lembert  sutures  in  the  stomach- 
wall,  but  required  further  anesthesia  in  closing  the  external  incision. 
This  lack  of  sensitiveness  in  the  visceral  peritoneum  has  been 
pointed  out  by  Greig  Smith.  The  patient's  recovery  was  prompt, 
and  the  gain  in  weight  remarkable. 

For  inoperable  obstruction,  such  as  advanced  malignant  dis- 
ease, gastro-enterostomy  is  the  operation  of  choice.  Anastomosis 
by  means  of  bone  plates,  inaugurated  by  Senn,  first  popularized 


.MKCHAMCAL  CAUSES   1.NTEU1-E1U.\(;    WITH   (lASTlilC    ACTKJX       17 

lliis  ()|)('rati()ii.  It  iniiy,  liowover,  be  open  to  tlic  oljjcctioii  of  too 
small  an  opoiiinji;  with  too  large  a  coaptating  surface  for  future 
contraction.  The  suture  method  is  slow,  with  danger  of  leakage, 
and  since  the  average  j)atient  is  only  too  fre(juently  at  the  point 
of  collapse  from  chronic  starvation,  the  Murphy  l)utton,  even  with 
the  (lisatlvantage  of  its  possible  jiassage  backward  into  the  stomach 
rather  than  onward  into  the  intestine,  is  a  quick  and  safe  method. 
I  have  employed  the  ])utt()n  in  three  gastro-enterostomies — twice 
successfully  and  once  followed  by  death;  in  the  latter  case  the 
union  was  perfect,  although  the  patient,  on  the  verge  of  collapse 
from  starvation  due  to  advanced  malignant  obstruction,  succumbed 
to  exhaustion  on  the  fifth  day.  Of  the  two  that  recovered,  one  is 
alive  and  well,  with  a  gain  of  40  pounds  in  weight  at  the  present 
time,  one  and  one-half  years  after  the  operation.  This  patient  was 
suffering  from  acute  starvation,  and  his  condition  would  not  war- 
rant a  pylorectomy,  which  a  tumor  of  unknown  nature  indicated. 
In  making  a  gastro-enterostomy  the  jejunum  should  be  caught  to 
its  origin,  and  a  loop  formed  with  the  direction  of  its  peristalsis 
in  the  same  direction  as  the  stomach,  to  prevent  impaction  of  the 
upper  portion,  or,  as  Kocher  recommends,  transversely  to  the  axis 
of  the  stomach,  thus  allowing  gravity  to  aid  the  passage  of  the 
food  in  the  proper  direction.  The  cureting  of  gastric  cancer 
through  a  gastrotomy  wound,  as  advocated  by  Bernays,  has  little 
to  recommend  it.  Pylorectomy  is  but  infrequently  done.  Its 
frightful  mortality  in  malignant  disease  without  reported  perma- 
nent cures  is  not  encouraging.  The  reason  for  this  great  mortality 
lies  in  the  debilitated  and  starved  condition  of  the  patient  at  the 
time  operation  is  resorted  to,  although  Kocher  has  recently  re- 
ported five  primary  recoveries  out  of  seven  pylorectomies.  In  the 
case  previously  referred  to  of  tumor  of  doubtful  nature  obstructing 
the  pylorus,  in  which  the  stomach  and  jejumun  were  joined  with 
Murphy's  device,  it  was  my  intention  to  wait  until  the  patient  was 
in  better  physical  condition  as  a  result  of  the  gastro-enterostomy 
and  then,  at  a  secondary  operation,  resect  the  pylorus  and  com- 
pletely close  the  end  of  the  duodenum  and  the  stomach,  utilizing 
permanently  the  existing  fistula.     The  patient  received  so  much 


48  WILLL^M   J.    iLA.YO 

relief  from  the  first  operation  that  he  decHned  to  submit  to  any 
further  interference.  I  fully  believe  that  preliminary  gastro- 
enterostomy would  put  the  patient  in  much  better  condition  for 
the  major  operation,  and,  by  allowing  permanent  closure  of  both 
duodenum  and  stomach  at  the  points  of  section,  the  mortality 
would  be  greatly  reduced.  In  any  case  it  is  better,  as  pointed  out 
by  Bull,  to  carry  the  gastric  opening  well  away  from  the  dangerous 
suture  line. 

Brandt  has  treated  dilatation  of  the  stomach  caused  by  chronic 
catarrh  by  plaiting  its  anterior  wall  with  a  Lembert  suture,  and  he 
reports  great  benefit  from  this  procedure,  the  object  being  to  re- 
lieve the  dependent  portion,  allowing  gravity  to  aid  the  gastric 
contents  to  work  toward  the  pylorus.  Cases  of  chronic  dilatation 
of  this  character  are  usually  due  to  some  form  of  pyloric  obstruc- 
tion, and  the  operation  is,  therefore,  rarely  indicated. 

Among  the  external  causes  of  interference  with  the  stomach 
are  adhesions  of  the  pylorus  or  duodenum  to  the  gall-bladder,  due 
to  the  inflammation  excited  by  gall-stone. 

The  most  common  cause  of  external  interference  with  the 
action  of  the  stomach  is  the  fixation  of  some  portion  of  the  omen- 
tum in  a  hernial  ring,  producing  traction  upon  the  stomach,  and 
of  these  incarcerated  omental  hernias,  the  least  often  recognized 
are  the  button-like  protrusions  through  little  defects  in  the  median 
line  above  the  umbiHcus.  We  have  operated  upon  a  small  number 
of  such  cases,  with  marked  relief  to  gastric  symptoms. 

Irreducible  omental  hernias  of  any  variety  are  almost  always 
accompanied  by  gastric  distress,  and  it  is  the  rule  that  this  dis- 
appears after  the  radical  cure  of  the  hernia.  Not  only  do  omental 
adhesions  cause  distress,  but  they  may  fix  or  distort  the  stomach  to 
an  astonishing  extent  without  symptoms  directing  attention  to  the 
hernial  protrusions.  In  one  instance  a  male,  fifty-four  years  of 
age,  had  suffered  for  seventeen  years  from  gastric  pain  and 
chronic  indigestion.  Test-meals  showed  free  acid.  On  dilating  the 
stomach  with  air  it  was  found  to  expand  to  a  remarkable  degree 
downward  and  to  the  right;  careful  examination  revealed  an  old 
irreducible  omental  hernia  of  small  size  on  the  right  side,  which  had 


MIOCIIAMCAI.   CAT'SES    INTERFFOUI  \C;    WITH    <;A>THI(     A(   TION        1!» 

existed  lor  years.  Itadical  oper;!!  ion  on  I  In- licrnia,  w  il  li  lilx-ratioii 
ol"  liic  omentum,  proniplly  relie\-e(l  llie  s_\iii|)lonis.  'J'liese  cases 
are  common.  Chronic  gastric  distress  following  alxh^niinal  o|)era- 
tion  is  not  infre(|iieiilly  dii(>  to  post -operative  adhesions  of  l)rni■^(•d 
or  ligaled  onienlimi,  and  may  necessitate  secondary  oi;eralioii  lor 
I  heir  iiheral  ion. 


CICATRICIAL    STENOSIS    AND    VALVE    FOR- 
MATION A  CAUSE  OF  PYLORIC 
OBSTRUCTION 

A  REPORT  OF  FIVE  CASES  RELIEVED  BY  OPERATION* 

WILLIAM   J.    MAYO 


Non-malignant  forms  of  pyloric  obstruction  are  not  infrequent, 
and  with  some  exceptions  have  been  so  commonly  confused  with 
cancerous  disease  that  patients  have  been  allowed  to  die  without 
surgical  intervention. 

When  the  stenosis  results  from  the  cicatrization  of  an  ulcer 
which  existed  years  previously,  the  patient  may  be  in  middle  life 
or  later  before  the  obstruction  becomes  marked,  and  the  cachexia 
of  chronic  starvation  closely  simulates  that  of  malignant  disease. 

Now  and  then  cases  operated  upon  by  masters  in  the  art  of 
surgery,  e.  g.,  Senn,  Lange,  Weir,  and  others,  have  been  reported 
in  American  literature.  European  surgeons  have  been  more 
advanced  in  this  respect,  and  have  furnished  many  important 
contributions  to  the  subject. 

Stricture  of  the  pylorus  following  upon  the  healing  of  gastric 
ulcer  is  the  most  common  form  of  non-malignant  obstruction,  and 
4  out  of  5  cases  upon  which  I  have  operated  have  been  of  this 
variety.  The  site  of  previous  ulceration  in  these  cases  was  along 
the  lesser  curvature  and  anterior  surface  of  the  stomach,  and  in  2 
the  cicatrix  was  very  extensive,  a  prolongation  extending  downward 
in  the  pyloric  region  and  causing  great  distortion  of  the  canal. 
In  2  of  the  remaining  cases  the  strictured  area  was  narrow  and 

*Presented  to  tlie  Section  on  Surgery  and  Anatomy  of  the  Amer.  Med.  Assoc, 
Philadelphia,  June,  1897.  Reprinted  from  "Jour.  Amer.  Med.  Assoc,"  October 
If),  1897. 

50 


SO.MK    CAISKS    OK    rVLOHK"    OUSTHITTION'  ."51 

circular  in  form,  one  with  its  origin  in  a  cicatrix  along  the  anterior 
wall  and  the  otluT  luiving  no  apparent  cause.  In  these  2  eases 
the  dilatation  of  the  stomach  was  extreme,  although  the  mechan- 
ical obstacles  to  its  emptying  were  not  so  great  as  in  the  3  cases  in 
which  the  scar  tissue  was  more  extensive.  In  1  of  the  '■I  cases  the 
pylorus  was  held  up  very  high  by  a  short  gastrolie|)atic  omentum, 
and  in  both  cases  the  downward  sagging  of  the  stomach  produced 
a  well-marked  kinking  or  valve  formation  at  the  pylorus,  which 
was  evidently  obstructive  in  its  nature. 

In  a  patient  who  died  from  chronic  starvation,  supposed  to  be 
due  to  pyloric  obstruction  of  a  cancerous  form,  and  therefore  not 
subjected  to  operation,  the  postmortem  showed  a  large  fibrous 
hypertrophy  with  obstruction,  such  as  described  by  Greig  Smith. 
The  pylorus  was  stenosed,  yet  not  to  a  marked  degree,  the  stric- 
tured  portion  easily  admitting  a  lead-pencil.  There  was  no  e\i- 
dence  of  ])rcvious  ulceration.  Here  again  this  valve  formation 
was  well  marked. 

Some  observations  of  the  2  cases  operated  upon  and  cxj^ieri- 
ments  made  with  the  postmortem  findings  just  referred  to  lead 
me  to  believe  that  a  pylorus  somewhat  rigidly  held  upward  by  a 
short  gastrohej)atic  omentum,  or  one  in  which  a  certain  amount 
of  mechanical  obstruction  is  present,  will  permit  sagging  of  the 
stomach  and  valve  formation  of  the  pylorus,  with  consequent  ob- 
struction. 

It  is  possible  that  this  condition  may  exist  in  many  cases  of 
chronic  gastric  catarrh  and  dilatation  without  producing  suflBcient 
trouble  to  cause  death  or  require  operation. 

The  production  of  valve  formation  at  the  pylorus  is  similar  to 
the  valve  formation  of  the  ureter  at  the  pelvis  of  the  kidney  as  a 
cause  of  hydronephrosis  and  pyonephrosis,  so  graphically  por- 
trayed by  Christian  Fenger. 

Enteroi)tosis  favors  such  obstruction,  as  the  greater  the  sagging 
of  the  intestines  and  the  greater  the  downward  displacement  of 
the  stomach,  the  more  perfect  are  the  mechanical  conditions  which 
tend  to  valve  formation. 

One  year  ago  I  read  a  paper  before  this  section  on  a  similar 


52  WILLIAM   J.    MAYO 

subject,  and  referred  to  valve  formation  as  a  possible  cause  of  the 
difficulty  at  the  outlet  of  the  stomach,  and  I  am  now  still  more 
confirmed  in  the  belief  then  expressed.  It  certainly  explains  many 
of  the  changes  incident  to  the  causation  of  obstructive  symptoms 
without  previous  local  disease. 

Kussmaul  has  been  able  to  produce  on  the  cadaver  a  rotation 
obstruction  which  is  evidently  similar  in  nature.  A  few  cases  of 
congenital  stricture  have  been  reported  by  Landerer  and  Maier, 

It  is  altogether  questionable  whether  movable  kidney  can 
produce  mechanical  pyloric  obstruction,  although  this  conclusion 
has  been  drawn  as  to  the  relief  of  gastric  symptoms  supposed  to  be 
given  by  nephrorrhaphy  in  neurasthenic  women. 

The  diagnosis  of  marked  pyloric  obstruction  and  the  consequent 
dilatation  of  the  stomach  is  not  difficult — in  fact,  the  vomiting  of 
large  quantities  of  ingested  material  or  its  removal  by  the  stomach- 
tube  is  of  itself  significant.  After  inflating  the  stomach  with 
atmospheric  air  by  means  of  an  ordinary  valve  syringe  and  a 
stomach-tube,  its  outline  can  be  rendered  evident  to  the  usual 
methods  of  physical  diagnosis,  inspection,  palpation,  percussion, 
and  auscultation.  The  gastroscope  and  the  gastrodiaphanoscope 
have  little  practical  value  to  the  surgeon.  The  differentiation 
between  the  malignant  and  the  non-malignant  forms  of  obstruc- 
tion is  often  difficult  and  may  be  impossible  without  exploratory 
incision.  The  examination  of  the  stomach-contents  has  some 
value.  When  the  test-meal  of  Ewald  and  Boas  shows  an  absence 
of  free  hydrochloric  acid  with  Giinzburg's  test  and  at  the  same 
time  shows  lactic  acid  by  Uffelmann's  method  of  examination,  the 
indications  are  for  cancer;  yet  prolonged  non-malignant  obstruc- 
tion may  cause  such  disease  of  the  mucous  membrane  as  to  mislead 
the  observer.  In  a  considerable  number  of  such  examinations 
made  by  Graham  the  conclusions  of  Rosenheim  have  usually  ob- 
tained, but  these  tests  are  far  from  reliable  in  character  and  at  best 
are  only  confirmatory. 

In  2  of  my  cases  of  obstruction  from  former  ulceration  the 
cicatricial  mass  could  be  so  plainly  felt  through  the  abdominal 
walls  as  to  lead  to  a  fear  of  malignant  tumor. 


S(hMK    CAUSES    OF    I'VLOKIC    OHSTKL(  TIO.N  53 

Afirr  all,  llic  cliiof  faclors  in  the  difrcrcntial  diii^iiosis  will  he 
obtained  i'roin  a  carclul  examination  into  the  personal  history  of 
the  patient,  esjjeeially  as  to  previous  uleeration,  and  from  the 
lenfi;tii  of  time  the  obstruction  has  existed.  In  this  respect  the 
occasional  cases  wherein  the  scar  tissue  of  previous  ulceration  has 
degenerated  into  inalif,niancy  are  of  interest. 

I  wish  to  call  attention  to  the  significance  of  enlarged  glands 
in  the  greater  and  lesser  omenta  as  evidence  of  malignancy. 

I  have  on  three  occasions  observed  enlarged  glands  having  all 
the  appearance  of  malignant  disease  in  non-malignant  pyloric  ob- 
struction, evidently  due  to  chronic  sepsis  from  the  absorption  into 
the  lymphatics  of  decomposing  stomach-contents. 

In  his  article,  "The  Floating  Stone  in  the  Common  Duct," 
Fenger  speaks  of  this  septic  glandular  enlargement  about  the  head 
of  the  pancreas  as  nowise  malignant.  I  have  found  it  in  one  case 
in  the  axilla  in  a  non-malignant  tumor  of  the  breast,  and  in  the 
deep  lymphatics  in  a  case  of  sloughing  uterine  fibroids. 

Bull  says  that  50  per  cent,  of  pyloric  cancer  patients  die  of 
starvation  before  glandular  infection  takes  place. 

In  his  work  on  "The  Surgery  of  the  Alimentary  Canal"  May- 
lard  speaks  of  the  large  fibrous  stricture  of  the  pylorus  as  having 
only  fibrous  structure,  but  says  that  if  epithelial  elements  be  found 
in  the  enlarged  glands,  malignancy  is  established.  I  think  that 
the  accuracy  of  statements  can  be  questioned  as  to  the  absolute 
malignancy  of  any  case  in  which  the  proof  is  enlarged  glands 
which  have  not  been  microscopically  examined. 

Operations  for  the  Relief  of  Pyloric  Obstruction 
The  median  abdominal  incision  between  the  ensiform  cartilage 
and  the  umbilicus  has  proved  to  be  the  most  satisfactory  in  giving 
easy  access  to  the  field  of  operation.  This  can  be  enlarged  by  a 
transverse  cut  across  the  rectus  muscle,  if  necessary  for  free  ex- 
posure. 

Pyloroplasty,  devised  by  Heineke  and  Mikulicz,  is  the  opera- 
tion of  choice,  and  in  narrow  strictures  is  easy  and  certain  in  its 
results.     As   much  of  the   incision  as  possible  should  be  in  the 


54 


WILLIAM   J.    MAYO 


healthy  rather  than  in  the  scar  tissue,  as  the  latter  is  stiff  and  does 
not  coapt  nicely,  and  has  the  disadvantage  of  all  scar  tissue  that 
necrosis  is  apt  to  be  the  result  of  the  suture  pressure.  If  the  con- 
tracted portion  is  very  long,  the  duodenum  can  be  folded  or 
knuckled  upon  the  stomach  after  the  adossement  method  of  the 
French  surgeons.  This  latter  plan  worked  admirably  in  the  second 
operation  on  my  fifth  case.  As  pyloroplasty  cannot  be  readily 
performed  in  severe  cases  in  which  the  scar  tissue  is  very  extensive 


Fig.  5. — Showing  the  maimer  in  which  the  first  two  stitches  are  applied.  The  forceps  serve  as 
retractors  to  hold  the  wound  apart,  as  shown  in  Fig.  6.  These  stitches  are  inserted  before  the  incision 
is  made. 


or  the  pylorus  bound  down  by  adhesions  to  a  degree  which  renders 
the  operation  hazardous,  the  mortality  should  not  be  great — about 
10  per  cent.  Out  of  5  cases  I  was  able  to  do  pyloroplasty  in 
only  2. 

Gastrorrhaphy,  introduced  by  Bircher,  may  be  a  good  opera- 
tion in  valve  formation,  but  cases  which  are  suitable  to  this  pro- 
cedure could  be  relieved  by  pyloroplasty. 


SOME    CArSE.s    Ol     I'VLOItK     OUSTUl  (  TION  O.J 

r.orcla's  ofXTalioii  of  diviilsion  has  a  inorlality  of  40  [xt  cciil., 
and  fails  in  a  larj^'c  proportion  of  tlic  cases,  making  a  primary 
recovery,  to  yield  a  p(  rniaiiciil  cnrt-.  Greig  Smith,  however. 
})elieves  that  it  has  a  fiekl  in  the  hir^e  fihrous  form  of  obstruction. 

Pylorectomy  will  seldom  he  done  for  non-mali^'nant  stricture. 
I  can  understand  how  a  surj^eon  could  conunence  a  pyloroplasty 
and,  (iridinu  this  incHiod  iinsiiitai)l(',  he  forci'd  to  make  a  pylorec- 


Fig.  6. — Showing  the  wound  drawn  transversely,  with  a  few  interrupted  sutures  in  place. 


tomy  as  the  only  way  out  of  the  difficulty,  hut  the  mortality  of  30 
per  cent,  is  too  high  when  contrasted  with  other  methods  of  relief. 
Weir,  Meyer,  and  others  have  done  the  operation  succe.ssfully  in 
this  class  of  ca.ses. 

Gastro-enterostomy  for  non-malignant  disease  is  an  operation 
of  expediency  and  not  t)f  choice,  ("ircinustances  often  compel  its 
ii.se,  however,  as  extensive  contracture  of  the  pylorus  or  the  pres- 
ence of  tissue  unsuitahle  for  the  securitv  of  suture  union. 


56  WILLIAM  J.  :mayo 

Inaccessibility  of  the  field  of  operation,  by  reason  of  the  pres- 
ence of  dense  adhesions  to  important  structures,  is  also  an  im- 
portant indication.  For  one  or  more  of  these  reasons  3  of  my  5 
patients  were  relieved  by  gastro-enterostomy. 

This  operation  by  the  suture  methods,  according  to  McGill, 
gives  about  50  per  cent,  mortality,  and,  with  mechanical  aids, 
about  23  per  cent.  The  best  mechanical  device  is,  undoubtedly, 
the  Murphy  button.  The  greatest  drawback  to  its  use  is  the 
liability  of  the  button  dropping  backward  into  the  stomach  upon 
separation.  This  happened  in  3  out  of  8  gastro-enterostomies  in 
which  it  was  employed  in  this  clinic.  A  year  ago  I  suggested 
tying  a  string  to  the  intestinal  side  of  the  button  with  the  end  in  a 
double  bow-knot  eight  inches  away,  thinking  that  intestinal  action 
at  that  distance  from  the  site  of  the  adhesions  would  act  as  a 
kite-tail  guide  or  tractor.  In  three  cases  it  acted  admirably.  In  a 
fourth  case  the  button  had  not  appeared  when  the  patient  left 
the  hospital. 

Great  care  should  be  exercised  to  secure  the  jejunum  at  its 
origin  and  form  a  coil  as  close  as  possible  to  the  proximal  end. 
Rockwitz  says  that  the  union  should  be  made  so  that  the  intestinal 
and  gastric  peristalsis  will  be  in  the  same  direction,  to  prevent 
impaction  of  the  unused  portion  of  the  bowel.  Braun  advises 
entero-anastomosis  to  empty  the  duodenum  more  perfectly,  and 
Kocher  makes  a  right-angled  attachment  of  the  bowel  to  the 
stomach,  in  order  that  gravity  may  aid  the  downward  passage  of 
the  gastric  contents.  In  all  operations  in  this  region  the  omentum 
can  be  readily  fastened  with  a  few  sutures  in  such  a  position  as  to 
add  greatly  to  the  security  of  union.  The  unequal  thickness  of 
the  stomach  and  intestine  is  a  source  of  weakness  in  this  opera- 
tion. 

It  should  be  borne  in  mind  that  a  stomach  with  a  normal 
capacity  of  three  pints,  dilated  to  two  or  three  times  this  extent  at 
the  time  of  operation,  will  certainly  contract  after  relief  of  the 
obstruction,  that  this  contraction  will  effect  the  opening  and 
correspondingly  reduce  its  size  to  the  same  extent,  and  that  such 
harmful  contraction  may  not  necessarily  be  due  to  the  scar  tissue 


SOME    (  AFSES    or    PYLORIC    OBSTRITTION  .}  i 

forming  the  margins  of  the  fistula.     In  this  Hcs  tli«-  iiiiccrfniiily  of 
gastro-enterostf)my  as  a  permanent  opening. 

Taking  all  these  facts  into  consideration,  the  suture  method  of 
Wolfler  offers  the  fewest  objections,  as  the  opening  can  be  of  suf- 
ficient length  to  provide  for  future  contraction  and,  with  the  im- 
proving techuic  of  modern  methods  of  suturing,  the  luorfalily  will 
steadily  diminish. 


Fig.  7. — Showing  the  wound  as  closed  by  two  rows  of  continuous  Lembert  sutures  by  means  of 
the  needles  and  threads  used  in  the  original  sutures,  the  unthreaded  end  of  the  sutures  having  served 
as  retractors  as  well  as  for  the  purpose  of  indicating  the  extent  of  the  suturing  necessary. 


In  operations  on  the  stomach  the  emptying  of  this  viscus  should 
be  carefully  attended  to  previous  to  operation,  to  prevent  con- 
tamination of  the  wound  by  escaping  contents.  A  preliminary 
hypodermic  of  morphin  with  chloroform  anesthesia  has,  in  our 
hands,  best  controlled  the  tendency  to  retching  so  annoying  in 


58  willia:m  j.  imayo 

operations  of  this  character.  The  after-treatment  has  been  simple; 
morphin,  if  needed,  to  prevent  peristalsis,  and  rectal  feeding  for 
three  or  four  days,  with  strychnin  hypodermically  and  stimulants 
per  rectum  as  needed. 

Case  1. — Stricture  and  Valve  Formation;  Pyloroplasty. — 
M.  M.,  male,  aged  forty-six,  American,  admitted  to  St.  Mary's 
Hospital  January  10,  1895,  \n\h.  a  history  of  gastric  symptoms 
extending  over  a  period  of  seven  years.  For  the  past  two  years 
he  has  vomited  large  quantities  of  partially  digested  or  decompos- 
ing food  once  or  twice  in  every  twenty-four  hours.  He  has  grown 
weaker,  and  lost  about  100  pounds  in  weight.  Early  in  his  ill- 
ness he  vomited  blood  a  few  times  and  suffered  severe  pain  after 
taking  food. 

Physical  Examination. — Patient  very  much  emaciated,  heart's 
action  feeble,  mth  dilatation  of  the  right  ventricle.  With  the 
stomach-tube  a  large  quantity  of  gastric  contents  was  removed. 
Dilating  the  stomach  \sith  air,  it  was  found  to  extend  downward 
and  to  the  left,  to  a  point  on  a  Hne  with  the  anterior  superior 
spine  of  the  ilium.  The  pylorus  was  plainly  felt  on  a  level  with, 
and  to  the  right  of,  the  umbilicus.  Free  hydrochloric  acid  was 
present  in  the  test-meal. 

Operation  January  13,  1895.  A  small  cicatrix  was  found  on 
the  anterior  wall  of  the  pylorus,  and  from  this  a  band  incircled 
the  pylorus,  producing  a  stenosis  of  about  the  caliber  of  a  goose- 
quill.  The  sagging  of  the  stomach  was  very  marked,  produc- 
ing a  kinking  or  valve  formation  just  at  the  stenosed  area.  En- 
larged glands  were  found  in  the  mesentery,  having  the  usual 
appearance  of  mahgnant  disease.  Pyloroplasty  was  done,  and 
the  patient  discharged  February  15th,  cured.  When  seen  six 
months  later,  he  had  gained  70  pounds  in  weight  and  was  doing 
his  work  on  a  farm. 

Case  2. — Cicatricial  Stenosis;  Gastro-enterostomy . — W.  G., 
male,  aged  fifty-three,  German,  admitted  to  St.  Mary's  Hospital 
May  26,  1896,  with  a  history  of  ulcer  of  the  stomach  which  had 
caused  seA'ere  trouble  for  nine  years.  During  this  time  he  had 
been  unable  to  work,  and  was  more  or  less  constantly  under 
treatment.  For  three  years  he  had  been  unable  to  take  sohd 
food,  and  at  intervals  of  from  eighteen  to  thirty  hours  vomited 
up  great  quantities  of  material  from  his  stomach. 

Physical    E.ramination. — Patient    extremely    emaciated,    and 


SOMK    CAL'SKS    OF    I'VLOUIC    OIJ.STIU  (  TKjN  50 

SO  weak  as  to  lie  imaMe  to  walk  willioul  assistance.  On  dilating' 
the  stomach  with  air,  it  filled  ;ilniost,  the  uhoie  ol"  tiie  left  side  ol' 
the  ahdonion.  Examinations  of  stomach-contents  were  con- 
tradictory and  uncertain.  To  the  right  of  the  umhiHciis  a  thick- 
ened area,  amounting  ahiiost  to  a  tumor,  could  be  felt. 

Operation  May  !^Oth.  A  very  extensive,  hoard-like  <icatrix 
was  found  on  the  lesser  curvature  of  the  stomach  and  ext<"nding 
into  the  pyloric  region.  The  strictured  area  was  extensive,  hound 
down  hy  dense  adhesions,  and  showed  practically  no  tissue  which 
would  he  safe  to  suture.  Gastro-enterostomy  was  done  with  a 
Murphy  button  and  string  guide.  Button  pnssed  on  the  thirteenth 
day;  i)atient  discharged  June  lOtii.  When  seen  two  months 
later  he  had  gained  30  pounds  in  weight  and  was  completely 
relieved  of  his  trouble.  When  seen  last  (ten  months  after  the 
operation),  patient  looked  fat  and  well,  ))ut  exhibited  some  synif)- 
toms  of  possible  contraction  of  the  opening.  Should  these  symp- 
toms become  sufficiently  marked,  I  shall  enlarge  the  gastro-enter- 
ostomy opening  by  an  operation  similar  to  pyloroplasty. 

Case  3. — Cicatricial  Stenosis;  Gastro-enterostomy. — Mrs.  J.  E., 
aged  fifty-five,  admitted  to  St.  Mary's  Hospital  July  6,  189G, 
with  a  history  of  chronic  stomach  trouble  extending  over  a  period 
of  fifteen  years.  She  had  been  unable  to  eat  solid  food  for  several 
years,  and  vomited  large  quantities  once  or  twice  in  twenty-four 
hours. 

Physical  Examination. — An  enlargement  felt  to  the  right  of 
the  umbilicus.  The  abdomen  protuberant  and  distended  with 
gas.  On  examination  this  distention  found  to  be  due  to  an 
enormously  dilated  stomach.  Examination  of  stomach-contents 
shows  free  hydrochloric  acid,  but  the  tests  were  not  very  satis- 
factory.    Patient  very  much  emaciated. 

Operation  July  10,  1896.  An  extensive  cicatrix  found  on  the 
lesser  curvature  and  in  the  pyloric  region.  The  pylorus  was 
contracted  extensively  and  felt  like  cartilage.  Enlarged  glands 
were  found  in  the  omentum.  Extensive  adhesions  rendered  the 
field  inaccessible,  and  the  stiffness  and  extent  of  the  stenosis  made 
gastro-enterostomy  expedient.  This  was  readily  done  with  the 
Murphy  button.  Imperfect  preliminary  removal  of  gastric 
contents  made  the  operation  difficult  on  account  of  escaping 
fluids  after  the  stomach  was  opened.  Uneventful  recovery,  with 
rapid  gain  in  both  strength  and  weight. 

Case  4. — Cicatricial  Stricture:  Pyloroplasty.     (Three   month.s 


60  WILLIAM   J.    MAYO 

after  adossement  for  recontraction.) — M.  St.  G.,  male,  aged  fifty, 
admitted  to  St.  Mary's  Hospital  January  18,  1897,  with  a  history 
of  chronic  gastric  disease  for  twenty  years.  At  times  there  would 
be  complete  relief  of  symptoms  for  some  months,  until  about  three 
years  ago,  since  which  time  he  has  been  in  constant  distress. 
He  is  unable  to  eat  solid  food,  and  for  a  year  has  vomited  a  large 
percentage  of  the  food  taken. 

Physical  Examination. — An  emaciated  man  with  a  greatly 
dilated  stomach,  which  contained  much  of  the  food  taken  twenty- 
four  hours  before.     Test-meals  show  free  hydrochloric  acid. 

Operation  January  21,  1897.  A  pyloric  obstruction  due  to 
stricture,  having  its  origin  in  an  ulcer.  Adhesions  to  the  liver 
and  gall-bladder  rendered  elevation  into  the  wound  difficult. 
Pyloroplasty  was  done,  some  of  the  sutures  being  necessarily 
placed  in  the  scar  tissue.  Patient  discharged  in  good  condition 
February  15th.  When  seen  April  1st  he  had  gained  25  pounds 
in  weight  and  said  he  could  eat  anything. 

April  15th:  Was  readmitted  to  hospital  suffering  from  fre- 
quent vomiting  and  symptoms  of  acute  obstruction  at  the  pylorus, 
which  had  come  on  suddenly  ten  days  previously. 

April  16th:  The  abdomen  was  opened  in  the  middle  line  and, 
as  the  pyloric  mass  lay  to  the  right,  the  rectus  muscle  on  this 
side  was  cut  across  just  above  the  umbilicus,  giving  free  expo- 
sure. Adhesions  to  the  gall-bladder  and  liver  rendered  inspection 
of  the  strictured  area  a  matter  of  great  difficulty,  and  during  the 
separation  the  pylorus  at  the  seat  of  the  stricture  was  opened 
widely,  one  wall  being  composed  of  the  liver.  It  could  now  be 
seen  that  the  sutures  in  the  scar  tissue  had  given  way,  and  adhesions 
to  the  liver  had  prevented  leakage  at  the  time,  but  these  adhesions 
had  been  largely  responsible  for  the  recontraction.  A  long  incision 
was  made  with  its  center  at  the  opening  in  the  pylorus,  and  the 
stomach  folded  over  the  nearly  immovable  duodenum,  after  the 
fashion  of  adossement,  as  described  by  Pilcher  in  his  article  on 
"Fecal  Fistula"  in  Dennis'  "System  of  Surgery."  Over  this  the 
neighboring  tissues  were  carefully  drawn.  The  patient  made  an 
uninterrupted  recovery. 

Case  5. — Stricture  and  Valve  Formation;  Gastro-enterostomy. — 
B.  K.,  male,  aged  forty -four,  admitted  to  St.  Mary's  Hospital 
March  22,  1897,  with  a  history  of  stomach  trouble  for  five  years, 
during  which  time  he  had  lost  80  pounds  in  weight.  He  does  not 
vomit,  but  for  three  years  has  used  a  stomach-tube  and  removes 


SOMi:    CACSKS    OF    I'VI.OUIf    OBSTRITTIOX  61 

hy  Lliis  iia-uns  a  large  qiianlily  of  partially  ciigt'.-<tccl  food  from  his 
stomach  once  or  twice  a  day. 

Physical  Exatninaiion. — On  distending  the  stomach  with  air 
it  fills  tiie  who.le  left  side  (»f  the  alxloinen  and  extends  across  into 
the  right  hypochoiidriinn.  Test-meals  show  free  hydrochloric 
acid. 

Operation  March  2'2,  1897.  Pylorus  held  high  hy  a  short 
gastrohepatic  omentum.  A  circ-ular  stricture  and  marked  valve 
formation  were  made  out.  Enlargetl  glands  were  found  in  the 
omentum.  The  field  of  operation  lay  well  under  the  liver,  in  a 
situation  which  precluded  a  safe  suture  operation.  Gastro- 
enterostomy was  done  with  a  Murphy  button  and  string  guide. 
Button  had  not  passed  when  patient  left  the  hospital  April 
!20th;  otherwise  he  had  made  an  uninterrupted  recovery,  with 
entire  relief  of  symptoms  and  steady  gain  in  weight  and  strength. 


OBSERVATIONS     ON    THE    DIAGNOSIS    AND 

SURGICAL  TREATMENT  OF  CERTAIN 

DISEASES  OF  THE  STOMACH* 

WILLIAM   J.    MAYO 


In  the  short  paper  which  I  have  the  honor  to  present  to  you 
this  evening  I  have  avoided,  so  far  as  possible,  reference  to  tlie 
work  of  many  observers  in  this  field  of  surgery,  especially  those 
whose  efforts  have  become  a  matter  of  history.  This  is  not  due  to 
a  lack  of  appreciation  of  the  pioneers  in  gastric  surgery,  but  rather 
to  the  extent  of  territory  which  I  have  attempted  to  cover.  The 
patients  which  form  the  basis  of  this  discussion  have  been  operated 
upon,  with  few  exceptions,  in  St.  Mary's  Hospital.  Our  experience 
in  this  field  comprises  26  cases  in  which  the  stomach  itself  had 
been  the  object  of  attack,  and  25  cases  in  which  operations  were 
made  for  the  relief  of  marked  gastric  distress,  caused  either  by 
adhesions  between  the  stomach  and  the  gall-bladder,  duodenum, 
or  neighboring  organs,  to  adherent  omentum  in  hernial  pouches, 
or  to  ventral  hernias.  This  makes  a  rather  natural  division  into 
two  general  classes: 

1.  Those  due  to  causes  acting  from  within  the  stomach. 

2.  Those  due  to  causes  acting  outside  the  stomach. 

There  are  a  few  facts  in  regard  to  the  anatomy  of  the  stomach 
which  are  of  so  much  importance  in  its  surgical  relations  that  I 
take  the  liberty  of  referring  to  them.  The  blood-supply  is  from 
three  principal  sources,  and  the  various  anastomoses  are  so  com- 
plete as  to  resemble  the  palmar  arch  or  the  circle  of  Willis. 

This   enormous    blood-supply   allows   free   incisions   into   the 

*Read  before  the  meeting  of  the  Minneapolis  Academy  of  Medicine  at  Minne- 
apolis, February  i,  1898. 

62 


OBSERVATIONS    OX    CERTAIN    DISEASES    OF    STOMA (11  <).'{ 

stomacli-walls  or  rosoctions  of  any  desired  aniount.  and  gives  a 
eertainfy  of  wcll-iiourislicd  flaps.  In  this  resjjcct  the  stomach 
differs  vastly  from  the  intestines,  in  wliieh  the  utmost  care  as  to 
nourisliment  of  the  bowel  perij)hery  is  of  so  much  importance  in 
dealing  with  the  mesentery. 

The  smaller  vessels  lie  along  the  surface  of  the  mucous  mem- 
brane. This  structure  is  very  thick  and  easily  separated  from 
the  outer  coverings.  Independent  suture  of  the  mucous  coat, 
therefore,  gives  firmness  and  checks  oozing. 

The  gastrohepatic  omentum  anchors  the  stomach  well  under 
the  ribs,  and  if  this  is  divided  first,  the  pylorus  and  lesser  curvature 
can  be  delivered  easily,  and  the  fingers  pass  at  once  behind  the 
stomach  and  pylorus  into  the  lesser  cavity  of  the  peritoneum.  In 
operations  upon  the  living  subject,  and  in  a  number  of  cadavers, 
the  value  of  this  mano^uver  was  readily  demonstrated. 

Volumes  have  been  written  about  the  functions  of  the  stomach, 
especially  by  the  specialist  in  internal  medicine,  but  to  the  surgeon 
the  mechanical  theories  have  the  greatest  attraction.  The  stom- 
ach represents  a  combination  of  the  hopper  and  the  silo.  The 
fundus  can  be  compared  to  the  magazine  of  a  coal-stove,  making 
it  self-feeding,  while  the  great  muscular  power  of  the  pyloric 
region,  with  the  aid  of  a  weak  solution  of  pepsin  and  hydrochloric 
acid,  softens  the  food  masses  and  passes  them  slowly  into  the  in- 
testines for  digestion  and  absorption.  As  Wendt  points  out,  the 
stomach  also  absorbs  fluids,  prevents  intestinal  overloading,  and 
corrects  the  varying  temperatures  of  the  ingesta.  The  gastric 
juices,  while  not  markedly  antiseptic,  are  hostile  to  germ  growth — 
a  factor  of  considerable  importance. 

Cancer  of  the  Stomach. — The  differential  diagnosis  of  cancer  of 
the  stomach,  especially  the  obstructive  type,  maj'  be  difficult, 
and  many  patients  have  perished  because  of  this  too  ready  opinion 
based  upon  insufficient  evidence.  The  history  in  cancer  of  the 
stomach  is  of  the  greatest  importance.  The  patients  can  usually 
fix  a  time  in  which  the  symptoms  Ijecame  marked — not  a  definite 
date,  but  a  period  within  from  one  month  to  three  months,  in 
which,  they  will  state,  the  disease  became  very  noticeable,  and 
from  which  time  the  symptoms  had  been  more  or  less  continuous. 


64  WILLIAM   J.    MAYO 

In  cicatricial  stenosis  the  history  covers  a  longer  period  of  time. 
The  not  infrequent  mahgnant  degeneration  of  former  scars  is 
confusing  in  this  respect. 

Vomiting  is  a  symptom  of  some  value.  In  pyloric  obstruction 
it  is  usually  infrequent, — once  or  twice  in  twenty -four  hours, — and 
a  large  quantity  of  material  is  ejected.  This  is  not  materially 
different  in  character  from  the  vomiting  due  to  cicatricial  pyloric 
obstruction.  The  obstruction  and  resulting  dilatation  of  the  stom- 
ach are  in  either  case  easily  demonstrated  by  filling  the  stomach 
^ath  air  through  a  stomach-tube  by  the  aid  of  an  enema  syringe. 
This  procedure  is  of  diagnostic  value;  it  also  aids  in  locating  the 
pylorus. 

In  cancerous  disease,  even  with  only  a  moderate  obstruction, 
vomiting  is  often  met  with,  and,  if  the  walls  of  the  stomach  are 
extensively  infiltrated,  vomiting  may  be  both  frequent  and  painful, 
resembling  that  due  to  ulcer.  Pain  and  emaciation  are  the  rule, 
and  I  am  always  suspicious  of  a  person  of  middle  or  later  life  who 
presents  these  symptoms,  with  a  cachexia  which,  while  not  peculiar 
to  cancer,  differs  from  the  pale,  bloodless  appearance  frequently 
accompanying  ulcer.  The  presence  of  a  tumor,  while  most  often 
noted  in  cancer,  may  be  found  in  cicatricial  contraction.  I  have 
several  times  felt  masses  of  this  character,  which  appeared  prior  to 
operation  to  be  too  well  marked  for  any  other  disease  than  malig- 
nancy. 

Examinations  of  test-meals  for  the  absence  of  hydrochloric 
acid  and  the  presence  of  lactic  acid  have  some  diagnostic  value. 
Graham  has  made  a  great  many  examinations  of  this  description, 
and,  as  a  whole,  they  have  been  fairly  satisfactory;  but  the  tests 
are  of  value  only  when  corroborated  by  other  testimony.  The 
tests  with  iodids  for  stomach  absorption  and  with  salol  as  to  the 
motor  power  are  essentially  laboratory  tests,  and  of  no  great  aid 
in  this  class  of  cases. 

The  gastroscope  and  gastrodiaphanoscope  are  thus  far  of  httle 
practical  use,  and  it  must  be  left  to  the  exploratory  incision  to  clear 
up  the  doubtful  cases  if  a  radical  cure  is  to  be  attempted. 

In  such  explorations  the  enlargement   covered  with  dilated 


OBSERVATION'S    0.\    f'KEtTMN     DISKASKS    OF    STOMA(  II  (i.> 

\'eiii.s  is  easily  tliilfrciili;it»'<|  I'mm  tin-  \\liili>li  scars  of  foriiicr 
ulceration,  while  the  exlcnl  of  the  disease  and  adhesions  to  im- 
portant viscera  render  the  radical  treatment  more  or  less  feasible. 

We  have  made  seven  exploratory  o[)erations  for  supf)osed  can- 
cer of  the  stomach.  In  one  case  the  tumor  |)roved  to  he  tuhercii- 
h)Ms  omenlniii,  aii<l  Ihc  |»atient  was  henefilt-d  Itv  the  exploration, 
as  often  happens  in  tiiherciiloiis  peritonitis.  Another  case,  thought 
at  the  time  to  be  cancer,  I  now  believe  to  have  been  a  benign  ob- 
struction. I  have  almost  alway.s  found  enlarged  glands  in  jjyloric 
obstruction,  whether  tlu'  disease  was  cancerous  or  not,  due  to 
chronic  sejjsis  from  the  al)sori)tiou  of  decomposing  gastric  con- 
tents, and,  unless  microscopic  examination  is  made,  such  findings 
are  of  small  value.  In  five  eases  the  cancer  was  inoperable.  In 
one  of  these  five  hopeless  cases  great  improvement  followed  ex- 
ploration, and  the  patient,  who  was  a  butcher,  worked  nearly  a 
year  at  his  trade  before  the  growth  again  became  active.  Similar 
cases  have  been  reported  by  Lawson  Tait.  J.  William  White  has 
investigated  this  and  kindred  phenomena,  in  which  tumors  had 
disappeared  or  the  condition  greatly  improved  after  exploratory 
manipulations,  and  reference  to  his  statistics  will  show  a  number 
of  such  cases. 

The  relatively  large  numl)er  of  such  explorations  is  a  confession 
of  failures  as  to  exact  diagnosis,  either  as  to  the  existing  condition 
or  as  to  the  stage  of  the  disease;  but,  since  an  exploration  is  the 
only  way  an  early  diagnosis  of  the  operable  cases  can  be  established, 
it  is,  in  my  opinion,  fully  justified. 

Unfortunately,  radical  operation  for  cancer  of  the  stomach 
depends  upon  an  early  and  often,  without  incision,  an  impossible 
diagnosis.  The  large  majority  of  cases  of  cancer  of  the  uterus 
are  not  seen  until  the  diagnosis  is  only  too  apparent  and  the  prog- 
nosis equally  so.  I  will  not  discuss  the  advisability  of  active  inter- 
ference in  this  otherwise  hopeless  malady,  and  can  only  say  that, 
in  our  experience,  the  results  have  been  satisfactory. 

We  have  made  three  gastro-enterostomies  and  three  pylorec- 
tomies  for  cancer;  one  of  the  gastro-enterostomies  proved  fatal 
from   bronchopneumonia  on  the  fourteenth   day,  due  to  the  as- 


66  -WILLI ATiI   J.    ]VL\YO 

piration  of  material  vomited  into  the  throat  during  the  manipula- 
tions. With  the  stomach  partly  out  of  the  abdomen,  the  elevation 
gravitated  the  contents  into  the  dependent  esophagus.  This 
should  have  been  avoided  by  raising  the  head  and  the  upper 
esophagus.  The  preliminary  emptying  and  cleansing  are  often 
more  apparent  than  real,  and  in  my  experience,  as  a  rule,  the 
stomach  at  the  operation  will  be  found  containing  a  considerable 
quantity  of  material,  although  emptied  and  washed  through  the 
tube  immediately  before  operation. 

The  remaining  patients  two  upon  whom  gastro-enterostomy  was 
performed  lived  for  a  year  or  more.  One,  from  a  state  of  starva- 
tion, not  only  gained  rapidly  in  flesh  and  strength,  but  labored  on  a 
farm  for  more  than  a  year.  The  second  was  comfortable  and  going 
about  nearly  a  year  afterward.  In  the  three  cases  of  pylorectomy 
all  the  patients  recovered  from  the  operation  and  are  now  in  good 
condition,  though  sufficient  time  has  not  elapsed  to  speak  of  them 
as  cured. 

The  method  of  pylorectomy  we  have  followed  has  been  speedy 
and  satisfactory.  The  ease  with  which  any  desired  amount  of 
stomach  can  be  excised  is  especially  noticeable — in  one  case  the 
upper  suture  angle  lying  behind  the  left  costal  arch  in  close  prox- 
imity to  the  cardiac  orifice  and  passing  obliquely  downward  and  to 
the  right  more  than  six  inches  in  length,  made  a  sort  of  shovel  nose 
to  the  amputated  end.  In  the  cases  referred  to,  and  also  in  a 
number  of  cadaver  operations  the  details  were  readily  carried  out. 
The  steps  are  as  follows: 

1.  A  median  incision  above  the  umbilicus,  and,  if  needed,  a 
cross-cut  of  the  rectus. 

2.  Double  ligation  and  division  of  the  necessary  amount  of 
gastrohepatic  omentum;  this  allows  the  pylorus  and  lesser  curva- 
ture to  be  delivered.  The  fingers  are  now  in  the  lesser  cavity  of 
the  peritoneum,  and  at  once  slip  under  the  pylorus  and  act  as  a 
guide  to  the  careful  double  ligation  and  division  of  the  gastrocolic 
omentum  attached  to  the  malignant  area. 

3.  The  diseased  part  is  isolated  by  a  piece  of  gauze  drawn  under 
it,  and  a  pair  of  forceps  are  caught  from  each  side,  separating  the 


orjsKin  atkjns  on  <  Hirr.M.N  uiskasks  of  sto.ma(  ii  <)7 

diseased  from  the  hejdtliy  stomach,  and  also  preventing  leakage 
from  below.  With  a  knife  a  cireular  cut  is  made  completely 
around  the  healthy  portion  of  the  stomach  to  the  mucous  coat. 
The  muscular  and  peritoneal  coats  are  stripped  back,  and  a  few 
bleeding  points  caught  with  forceps.  The  mucous  coat  is  cut 
inch  by  inch,  and  at  once  closed  with  a  continuous  catgut  suture; 
this  is  cut  short  and  the  detached  pylorus  and  tumor  are  covered 
and  turned  out  of  the  way.  A  second  continuous  catgut  suture  of 
the  muscular  coat  rolls  in  the  mucous  coat,  while  outside  of  this  a 
good  silk  Lembert  of  the  peritoneum  and  muscular  coats  protects 
and  rolls  in  the  two  first  rows  of  sutures. 

4.  The  end  of  the  stomach  is  slipped  to  the  right,  and  the  ends 
of  the  tied  omenta  are  sutured  to  each  other  and  to  the  suture  line, 
not  only  making  further  protection,  but  also  anchoring  the  stomach 
to  the  right  and  preventing  undue  traction  upon  the  duodenum 
after  it  is  fastened  in  place. 

5.  The  duodenum  is  cleanly  amputated  at  a  healthy  point, 
and  buttoned  with  a  Murphy  button  to  the  anterior  lower  wall  of 
the  stomach. 

We  performed  this  operation  once  in  forty-five  minutes,  once 
in  one  hour  and  five  minutes,  and  once  in  one  hour  and  twent}'- 
five  minutes.  I  mean  by  this,  from  the  time  the  operation  was 
commenced  until  the  dressings  were  in  place,  and  in  each  case  from 
four  to  six  and  one-half  inches  of  stomach  was  excised. 

Benign  Obstruction. — In  papers  read  before  the  meetings  of  the 
American  Medical  Association  in  1896,  and  again  in  1897,  I  called 
attention  to  valve  formation,  either  with  or  without  scar  contrac- 
tion. It  is  undoubtedly  a  common  condition,  and  responsible  for 
many  cases  of  dilated  stomach  which  were  believed  to  be  due  to 
chronic  gastritis. 

We  have  made  four  pyloroplasties  on  three  patients  and  five 
gastro-enterostoraies  for  cicatricial  stenosis  and  valve  formation. 
Of  the  pyloroplasties,  two  were  followed  by  good  results;  one  re- 
lapsed and,  after  a  second  pyloroplasty,  eventually  required  a 
gastro-enterostomy.  In  the  fourth  operation  we  made  an  inci- 
sion, three  or  four  inches  in  length,  and,  while  it  required  careful 


68  \\t;llloi  j.  :siato 

suturing,  the  opening  was  of  ample  and  permanent  size.  The 
method  of  suture  employed  by  Ochsner,  pubHshed  in  the  "Journal 
of  the  American  Medical  Association/"  October  16,  1S9T,  can 
be  commended  in  this  operation. 

Of  the  five  cases  of  gastro-enterostomy  for  cicatricial  stenosis, 
one  proved  fatal  from  aspiration  pneumonia  on  the  eleventh  day 
(this  patient  was  the  one  upon  whom  the  two  pyloroplasties  had 
failedV  The  four  remaining  patients  made  fine  and  so  far  per- 
manent recoveries.  TMiile  forced  in  each  instance  to  do  this 
operation  by  reason  of  extensive  adhesions  or  great  extent  of  scar 
tissue,  the  ultimate  results  have  been  uniformly  good — equally 
so  with  the  pyloroplasties,  which  were  done  in  easier  cases.  All 
our  gastro-enterostomies  have  been  button  operations.  The  mus- 
cular walls  of  the  stomach  in  cicatricial  stenosis  are  always  very 
thick — much  more  so  than  in  cancerous  disease,  on  account  of 
the  length  of  time  the  obstruction  has  existed.  For  this  reason 
the  walls  of  the  stomach  should  be  incised  to  the  mucous  coat  be- 
fore the  button  suture  is  put  in,  and  only  a  small  bit  of  these  tissues 
included  in  the  grasp  of  the  button,  to  prevent  its  hanging  too  long 
in  place.  In  all  of  our  cases  the  jejunum  was  caught  at  its  origin 
and  a  coil  formed  and  united  to  the  anterior  wall  of  the  stomach, 
in  such  fashion  as  would  not  cause  traction  or  kiuking;  and  in 
the  eight  gastro-enterostomies  none  of  the  cases  had  regurgitant 
vomiting. 

The  objection  to  the  ^Murphy  button,  that  it  may  be  retained 
in  the  stomach,  is  legitimate,  but  as  no  cases  have  been  reported 
in  which  such  retention  has  caused  harm,  and  experience  has  shown 
that  the  button  may  be  passed  after  the  patient  has  been  discharged 
as  cured,  the  objections  do  not  overcome  its  advantages  in  the 
wav  of  speed,  certainty  of  approximation,  and  permanency  of 
opening.  Two  years  ago  I  advised  a  " kite-tail"  guide  of  shk  to 
act  as  a  tractor  down  the  intestine;   the  value  of  this  is  uncertain. 

Gastrostomy  was  performed  three  times  for  stomach  feeding 
necessitated  by  esophageal  obstruction.  One  operation  was  made 
by  the  Fenger  method;  this  case  required  constant  attention  on 
account   of  leakage.     The  other  two  operations,  done  after  the 


OUSKUNATIONS    ON    CKUTAIN    DISEASES    OK    STOMA(  H  00 

Witzel  plan,  gaxc  ideal  resiills,  jind  I  have  not  heen  convinced  as 
to  the  snperiority  ot"  the  I'^rank  operation,  which  Meyer  and  others 
reeonnnend. 

Gastroriliaphy  was  done  in  one  ease  of  ginisjiot  woinid  of  the 
stomach  eight  honrs  after  the  injury,  and  the  large  wound  of  the 
anterior  wall  sutured;  the  patient  recovered.  The  patient  was 
brought  to  St.  ^Mary's  Hospital  as  quickly  as  possible  after  the 
accident,  and  to  this  pronii)t  aetiiju  the  good  result  was  undoubt- 
edly due. 

Causes  for  Gastric  Distress  Acting  from  Without  the  Stomach. — 
Cases  of  this  description  arc  very  common,  and  usually  due  to 
well-understood  conditions,  such  as  chronic  appendicitis,  intestinal 
adhesions,  movable  kidney,  and  similar  ailments;  hut  in  these 
instances  the  resulting  gastric  disturl)ance  is  largely  through  the 
nervous  system. 

There  are,  however,  a  number  of  cases  in  which  adhesions  of 
the  stomach  or  pylorus  to  a  neighboring  organ,  hampering  its  free 
action,  are  sources  of  more  or  less  disability,  and  the  separation  of 
these  adhesive  bands  will  relieve  the  difficulty. 

We  have  seen  three  such  eases — one  due  to  an  old  adherent 
gall-bladder  without  stones,  although  it  had  undoubtedly  once  con- 
tained them;  one  due  to  a  duodenal  ulcer,  with  a  mass  of  adhe- 
sions binding  the  pylorus  and  limiting  its  caliber;  one  was  prob- 
ably a  recurrent  regional  peritonitis  about  a  diseased  gall-bladder. 
This  caption  does  not  include  the  many  instances  of  gall-stones 
in  which  gastric  symptoms  were  present.  Such  residts  are  also 
easily  understood  when  the  omentum  has  become  adherent  to  a 
hernial  sac  and  remains  irreducible,  causing  a  certain  amount 
of  dragging  and  interfering  with  the  free  action  of  the  stomach. 
We  have  seen  this  hai)pen  three  times  in  umbilical  hernias, 
eight  times  in  inguinal  hernias,  and  three  times  in  femoral  her- 
nias, and  in  each  instance  release  of  the  adherent  omentum  and 
radical  operation  on  the  hernia  gave  complete  and  lasting  relief 
to  the  gastric  symptom.  In  these  cases  the  patients  came  com- 
plaining of  stomach  trouble  and  not  of  the  hernia.  The  list  does 
not  include  cases  in  which  the  intention  of  the  patient  was  merely 


70  WILLIAM   J.    MAYO 

to  be  rid  of  the  annoyance  of  the  hernia,  and  in  which,  as  a  part  of 
the  radical  cure,  the  omentum  was  freed. 

It  is  difficult  to  state  just  why  the  ventral  hernia  protrusion 
through  little  defects  in  the  median  line  above  the  umbilicus  should 
cause  gastric  distress.  Recent  literature  contains  many  reported 
cases.  In  our  earlier  operations  the  protrusion  was  always  believed 
to  be  omentum,  but  careful  dissection  has  shown  that  it  is  often 
preperitoneal  fat,  and  the  constant  congestion  causes  it  to  become 
lipomatous — a  condition  exceedingly  common  about  old  femoral 
hernial  sacs.  In  all  these  cases  of  ventral  hernia  a  glove-like  pro- 
trusion of  peritoneum  occupies  the  central  part,  and  this  may  be 
empty,  although  there  may  be  omentum  and  also  a  part  of  the 
fatty  contents  of  the  suspensory  ligament  of  the  liver  in  the  sac. 

In  closing,  I  cannot  do  better  than  quote  Mayo  Robson: 
"Although  difficult  to  lay  down  hard-and-fast  rules,  it  is  certainly 
wise,  in  cases  of  obscure  gastric  pain  producing  invalidism  or 
debility,  after  medical  treatment  has  been  fully  tried  and  failed 
to  open  the  abdomen  in  order  to  clear  up  the  diagnosis  and  then 
adopt  that  line  of  treatment  which  seems  indicated." 


i 


THE  DIAGNOSIS  AND  SURGICAL  TREATMENT 
OF  MALIGNANT  OBSTRLXTION  OF 
THE  PYLORUS* 

WILLIAM    J.    MAYO 


The  stomach  is  undoubtedly  the  most  common  seat  of  carci- 
noma. In  a  recent  paper  on  "The  Etiology  of  Tumors,"  read 
before  the  New  York  Surgical  Society,  Hartley  says  that  not  less 
than  34.97  per  cent,  of  all  carcinomata  are  to  be  found  in  the 
stomach,  and  he  points  out  clearly  the  relation  between  the  dis- 
ease and  the  chronic  irritation  to  which  the  stomach  is  subjected. 

Gussenbauer  and  Winiwarter  estimate  that  more  than  60  per 
cent,  of  gastric  cancers  are  at  the  pylorus,  and,  according  to  Bull, 
in  more  than  one-half  of  these  cases  the  mechanical  obstruction 
causes  death  before  glandular  infection  takes  place  or  the  infiltra- 
tion of  neighboring  structures  is  far  advanced. 

In  his  monumental  work  on  "Tumors"  Senn  says  that  the 
histologic  structure  of  cancer  of  this  organ  mimics  the  tubular 
glands,  while  the  character  of  the  tumor  is  determined  by  the  rela- 
tive amount  of  epithelial  cells  to  the  stroma.  This  is  well  shown 
by  the  clinical  history  of  the  case.  If  the  cell  structure  is  in  ex- 
cess, the  growth  is  active,  ulcerates  early,  and  glandular  infection 
occurs  so  quickly  that  the  diagnosis  will  seldom  be  made  in  time 
to  be  of  value.  In  this  class  of  cases  complete  gastrectomy  would 
be  the  only  procedure  indicated,  as  there  will  seldom  be  marked 
obstructive  symptoms  requiring  gastro-enterostomy  for  relief. 
The  successful  case  of  Schlatter  is  hardly  sufficient  to  give  the 
operation  a  permanent  position,  nor  can  the  cureting  of  the  growth 

•Reprinted  from  "Trans.  .\mer.  Med.  Assoc.,"  1898. 
71 


72  WILLIAM   J.    MAYO 

through  a  gastrotomy  incision,  as  practised  by  Bernays,  be  greatly 
commended  as  a  palliative  measure. 

That  variety  of  carcinoma  of  the  pylorus  in  which  the  stroma 
is  in  excess  quickly  produces  obstructive  symptoms  which  lead  to 
a  diagnosis,  and  the  nature  of  the  tumor  does  not  favor  early 
glandular  infection.  These  growths  are  often  annular  in  form, 
greatly  resembling  the  carcinomatous  structure  commonly  met 
with  in  the  colon.  Rarely  the  infiltration  may  involve  the  whole 
of  the  stomach,  without  special  contraction  of  the  pylorus,  the 
walls  being  of  enormous  thickness  and  the  cavity  small.  The  latter 
is  a  point  of  diagnostic  importance,  as  the  great  thickness  of  the 
stomach-wall  resembles  that  due  to  pyloric  obstruction  with  con- 
sequent dilatation.  Hektoen  recently  exhibited  two  marked 
specimens  of  general  gastric  cancer  before  the  Chicago  Medical 
Society.  The  large  fibrous  stricture  of  the  pylorus  described  by 
Greig  Smith  as  probably  non-malignant  greatly  resembles  general 
gastric  carcinosis.  Sections  showing  malignancy  are  difficult  to 
obtain  in  both  instances.  Maylard,  in  speaking  of  this  variety 
of  obstruction,  says  that  in  the  latter  stages  glandular  infection 
takes  place,  and  the  histologic  structure  of  the  adenopathy  is 
typically  carcinomatous. 

The  enormous  hypertrophy  of  the  walls  of  the  pylorus  may  form 
a  distinct  tumor,  and  these  cases  have  usually  been  treated  by 
gastro  -enterostomy . 

I  have  met  with  one  well-marked  example  of  this  so-called 
large  fibrous  stricture  of  the  pylorus  which  had  well-defined  limits. 
If  these  cases  are  malignant,  pylorectomy  is  indicated.  Clinical 
experience  will  soon  demonstrate  whether  or  not  they  are  cancerous. 

Rokitansky  long  ago  pointed  out  that  extension  of  any  form  of 
gastric  cancer  to  the  duodenum  seldom  took  place.  Sutton  de- 
scribes an  adenoma  as  a  rather  infrequent  tumor  of  the  pylorus, 
which  may  be  obstructive  in  nature  and  may  possibly  become 
malignant.  Sarcoma  of  this  region  is  so  rare  as  to  be  a  pathologic 
curiosity. 

The  diagnosis  of  obstruction  of  the  pylorus  and  resulting  dila- 
tation of  the  stomach  is  not  difficult.     Senn  has  taught  us  that 


MALIGNANT    OBSTKUCTION    OF    PVI-OKIS  I  .i 

when  the  fundus  lies  helow  the  level  of  the  umVjilicus,  there  is 
patlioloj^'ic  dilatation,  unless  gastroptosis  is  present.  Inspection 
of  the  ahdonien  in  marked  cases  will  often  reveal  the  outlines  «»f 
the  stomach,  and  if  it  be  distended,  percussion  will  produce  splash- 
ing sounds.  It  is  a  simple  expedient  in  the  diagnosis  of  dilatation 
to  pass  a  stomach-tube  and  inflate  the  cavity  with  air  by  means 
of  a  valve  syringe,  making  its  outlines  evident,  overdistention  re- 
lieving itself  around  the  tube. 

The  normal  stomach,  as  shown  by  Ilaslam,  is  contracted,  and 
its  walls  in  apposition  or  in  close  contact  with  ingesta.  The  differ- 
ential diagnosis  as  to  the  malignant  or  non-malignant  character 
of  the  obstruction  is  often  difficult,  and  occasionally  impossible, 
without  incision  of  the  abdominal  walls.  The  history  is  of  the 
utmost  importance.  A  long  history  and  a  slow  indefinite  course 
in  the  early  stages  are  against  cancer,  and  in  the  stenosis  due  to 
scar  contraction  an  early  history  of  painful  vomiting,  especially 
after  taking  food,  and  the  other  symptoms  of  previous  ulceration, 
are  often  brought  out. 

In  cancer  the  onset  may  be  insidious,  but  is  limited  to  a  few 
weeks  or  months,  rather  than  years.  In  the  latter  stages  the 
vomiting  of  great  quantities  of  partly  digested  food  at  intervals 
is  indicative  of  the  dilatation,  but  has  little  differential  value  as 
between  malignant  and  non-malignant  obstruction. 

The  presence  or  absence  of  a  tumor  has  some  significance  in 
connection  with  the  history.  In  11  cases  of  non-malignant  ob- 
struction 3  had  a  well-marked  tumor  of  the  pylorus  due  to  a 
thickened,  board-like  scar,  while  in  7  cases  of  cancer  operated 
upon,  in  3  no  enlargement  could  be  felt.  A  tumor  with  a  short 
history,  accompanied  by  a  cachexia,  which,  while  not  peculiar  to 
cancer,  is  of  such  frequent  occurrence  as  to  be  clinically  called 
"cancerous  cachexia,"  is  of  great  diagnostic  importance. 

What  shall  be  said  as  to  the  absence  of  free  hydrochloric  acid, 
or  presence  of  lactic  acid,  in  the  differentiation?  Graham  has 
made  systematic  examinations  of  such  cases  which  have  been 
admitted  to  St.  Mary's  Hospital  during  the  past  four  years.  In 
cancer,  the  absence  of  free  hydrochloric  acid  has  been  the  rule,  but 


74  WILLL^VM   J.    MAYO 

it  has  occasionalh^  been  absent  in  the  late  stages  of  non-malignant 
obstruction.  On  the  whole,  the  chemical  tests  have  been  dis- 
appointing. The  presence  or  absence  of  lactic  acid  varied  in  the 
same  case  at  diflFerent  tests,  while  the  iodid  test  for  absorption, 
and  salol  test  for  motor  power,  added  little  to  knowledge  more 
reliably  furnished  by  clinical  methods  in  common  use.  The 
gastroscope  and  the  gastrodiaphanoscope  do  not  give  encouraging 
results,  even  in  the  hands  of  their  advocates.  The  a:-ray  adds 
little  to  the  diagnosis,  although,  as  shown  by  the  cases  of  Meisen- 
bach  and  others,  it  is  of  value  if  foreign  bodies  are  contained 
in  the  stomach.  After  all,  of  what  great  value  is  the  prelim- 
inary exact  diagnosis  in  cases  of  marked  pyloric  obstruction,  as 
under  any  circumstances  surgical  intervention  is  necessary,  and 
the  earlier  it  is  instituted,  the  better  will  be  the  results?  As 
Haslam  says,  it  may  be  impossible,  with  the  growth  in  hand,  to 
tell  a  hard  carcinoma  from  a  fibrous  stricture,  or  a  beginning  can- 
cerous degeneration  of  the  scar  of  a  former  ulceration.  Other 
things  being  equal,  an  early  incision  for  the  purpose  of  diagnosis, 
to  be  extended,  if  feasible,  into  therapeutic  measures,  should  be 
the  rule. 

In  seven  cases  of  malignant  disease  explored  by  us  nothing 
further  was  done.  In  two  of  these  cases  great  improvement  fol- 
lowed; in  one  case  improvement  lasted  for  a  year.  Tait  long  ago 
called  attention  to  the  good  effect  upon  intra-abdominal  malig- 
nant disease  from  the  mere  incision  of  the  peritoneum. 

Upon  opening  the  abdomen  the  cancerous  nature  of  the  disease 
can  usually  be  readily  recognized  by  the  enlarged  tortuous  vessels 
in  the  peritoneal  covering,  so  different  from  the  whitish  scars  of 
former  ulceration.  The  nature  of  the  so-called  large  fibrous  stric- 
ture, upon  which  Loreta  first  performed  his  operation  of  digital 
divulsion,  is  in  doubt.  Whether  the  exploration  shall  end  as  such 
or  be  converted  into  the  first  step  of  a  pjdorectomy  or  of  a  gastro- 
enterostomy will  depend  upon  the  extent  and  character  of  the 
disease,  the  adhesions  to  surrounding  viscera,  and  the  condition  of 
the  glands. 

The  non-operative  treatment  consists  of  careful  regulation  of 


MALK.NANT    OnsTHlTTION    ()V    I'MAHlUH  75 

the  diet  and  the  use  of  bismuth,  salol,  and  jrastro-intestinal  anti- 
septics to  reheve  llie  alteiuhint  catarrh.  Coliius  thcjught  that  the 
internal  administration  of  1  grain  of  methyl-hlue  with  3  grains  of 
powdered  nutmeg  after  eating  was  of  great  l)enefit.  In  hopeless 
cases  Ochsner  practises  tlie  routine  use  of  tlie  stomach-tube  twice 
a  day  for  the  removal  of  the  unabsorbed  remains  of  ingesta  to 
prevent  irritation. 

There  are  at  j)resent  but  two  recognized  jjrocedurcs  which  can 
claim  serious  attention — pylorectomy,  a  radical  operation,  based 
on  the  hope  of  a  cure,  and  gastro-enterostomy,  for  palliative  pur- 
poses. 

Pylorectomy  is  not  a  popular  operation;  its  great  immediate 
mortality  (40  to  70  per  cent.)  and  the  few  cases  which  have  sur- 
vived the  three-year  time  limit  have  been  discouraging,  but  if  it 
is  a  fact  that  50  per  cent,  of  patients  with  pyloric  obstruction  die 
before  systematic  infection  takes  place,  an  early  operation  should 
give  better  results.  Bernays  takes  the  view  that  the  operation  is 
useless  unless  the  entire  stomach  be  removed,  seeming  to  class  it 
with  cancer  of  the  breast  or  uterus,  yet  in  cancer  of  the  colon,  which 
appears  often  as  a  stricture  and  produces  an  obstruction,  mechani- 
cal in  its  nature,  he  would  hardly  hold  the  analogy  complete  and 
advise  the  removal  of  the  entire  large  bowel. 

When  the  whole  riuestion  is  opened,  it  would  seem  that  the 
enormous  mortality  following  operation  has  really  been  the  ob- 
jection, and  the  only  patients  who  have  appeared  to  justify  the 
risk  have  passed  beyond  cure.  Improvements  in  technic  will  soon 
remove  much  of  this  objection.  Kocher  has  had  7  recoveries  out 
of  9  cases;  Pean,  8  recoveries  out  of  1-2  cases.  One  cause  of  the 
great  mortality  in  the  so-called  Billroth  method  was  imperfect 
union  and  resulting  leakage  at  the  suture  angle,  that  is,  at  the 
|)oint  where  the  narrowed  stomach  was  fitted  to  the  duodenum. 

The  performance  of  pylorectomy,  and  either  side-to-end  gas- 
troduodenostomy  or  side-to-side  gastrojejunostomy,  has  remedied 
this  weak  point  in  the  older  technic  and  is  now  usually  employed. 
Of  these  two  methods,  gastroduodenostomy  is  the  operation  of 
choice,  as  one  of  the  constant  dangers  is  the   so-called  regurgi- 


7o  WILLIAM  J.  :m-\yo 

tant  vomiting,  the  bile  and  pancreatic  juices  passing  into  the 
stomach  through  the  fistulous  opening,  rather  than  along  the  intes- 
tinal tract. 

On  three  occasions  the  pylorus  and  part  of  the  stomach  were 
successfully  removed.  These  patients  all  recovered  from  the  oper- 
ation, and  while  they  are  now  in  good  condition,  sufficient  time  has 
not  elapsed  to  speak  of  them  as  cured.  The  method  of  pylorectomy 
we  have  followed  has  been  speedy  and  satisfactory.  The  ease 
with  which  any  desired  amount  of  stomach  can  be  excised  is  es- 
pecially noticeable.  In  one  case  the  upper  suture  angle  was  lying 
behind  the  left  costal  arch,  in  close  proximity  to  the  cardiac  orifice, 
passing  obliquely  downward  and  to  the  right  more  than  six  inches 
in  length,  forming  a  "shovel  nose"  to  the  amputated  end. 

Gastro-enterostomy,  or  the  operation  of  Wolfler,  is  a  much 
more  popular  procedure  than  pylorectomy,  although  in  performing 
it  we  frankly  accept  the  inevitable.  This  operation  has  been  so 
thoroughly  discussed  by  Willy  Meyer  in  an  article  published  in 
the  "Annals  of  Surgery,"  July,  1897,  and  in  one  by  Weir,  pub- 
lished in  the  "  Medical  Record, "  April  16,1898,  that  I  will  not  de- 
scribe it. 

At  present  there  are  but  two  methods  of  gastro-enterostomy 
which  have  a  considerable  following:  The  suture  operation  and 
the  one  with  the  Murphy  button.  I  had  the  privilege  recently  of 
witnessing  Senn  do  the  suture  operation.  In  his  hands  it  seemed 
easy  and  was  certainly  rapid  and  satisfactory.  I  have  made  ten 
gastro-enterostomies,  four  only  for  malignant  disease,  with  one 
death.  All  my  operations  were  made  with  the  Murphy  button, 
and  neither  regurgitant  vomiting  nor  recontraction  occurred. 
One  non-malignant  case  is  now  of  over  three  years'  standing. 

The  collection  of  cases  reported  by  Meyer  and  Weir  shows  the 
great  frequency  and  fatal  character  of  the  regurgitant  vomit,  and 
the  importance  of  the  subject  is  shown  by  the  numerous  methods 
of  preventing  its  occurrence  by  Kocher,  Doyen,  Braun,  and  others. 
From  a  careful  study  of  histories  of  the  fatal  cases  in  which  this 
has  happened  I  believe  it  to  be  less  common  with  the  button  than 
with  the  suture.     The  method  of  gastrojejunostomy  which  we 


.malh;\a\t  omstiu  (Tkjn  of  iMLoitu.s  77 

have  followed  has  hccn  to  ^rasp  the  jejunum  at  its  origin  and  form 
a  coil  which  shall  he  sufficiently  free  to  attach  to  the  anterior  wall 
of  the  stomach  without  dragj^'ing.  usin<^  no  sutures  whatever. 

As  the  stomach-wall  is  very  thick,  it  should  be  cut  to  the  mu- 
cous coat  before  the  puckering  string  for  the  button  is  put  in,  and 
the  bite  of  the  suture  in  the  stomach-wall  should  not  be  great.  It 
occasionally  happens  that  the  button  will  drop  back  into  the 
stomach.  In  the  reported  cases  of  this  accident  it  has  caused  no 
harm,  and  not  infrequently  it  has  been  voided  weeks  or  months 
after  the  patient  has  passed  out  of  observation. 

I  think  too  much  importance  has  been  attached  to  the  question 
of  whether  the  bowel  shall  be  fixed  to  the  anterior  or  posterior  wall 
of  the  stomach;  the  results  seem  to  be  about  the  same  in  either 
case. 

A  few  words  in  regard  to  the  preparation  of  the  patient  before 
operating  upon  the  stomach.  It  has  been  my  experience  that  the 
l)reliminary  cleansing  and  emptying  of  the  stomach  has  not  been 
thoroughly  accomplished,  and  at  operation  the  stomach,  which 
was  apparently  empty,  will  be  found  to  contain  a  considerable 
amount  of  material.  As  this  viscus  is  elevated  outside  of  the 
abdominal  incision  during  the  operation,  this  fluid  may  gravitate 
into  the  dependent  esophagus  and  be  aspirated  into  the  lungs, 
causing  a  fatal  septic  pneumonia.  Great  care  on  the  part  of  the 
anesthetizer  is  necessary  to  prevent  this  accident. 

Case  1. — Cancer  of  the  Pylorus;  Pylorectomy  and  Gastroduo- 
denostomy. — B.  McD.,  female,  aged  sixty-one  years;  admitted  to 
St.  Mary's  Hospital  September  S^,  1897,  giving  a  history  of 
obscure  stomach  trouble  which  had  existed  for  several  years. 
Within  the  previous  six  months  the  character  of  the  distress  had 
changed,  and  was  accompanied  by  vomiting,  at  irregular  intervals, 
of  large  quantities  of  decomposed  food.  There  had  been  25 
j)ounds'  loss  of  weight. 

Physical  Examination. — Patient  somewhat  emaciated;  no 
tumor  could  be  discovered;  stomach  greatly  dilated;  no  free 
hydrochloric  acid. 

Operation  October  1,  1897.  A  carcinomatous  contraction  of 
the  pylorus  was  found;    no  glandular  enlargement.     Pylorectomy 


78  WILLIAM   J.    iL\YO 

and  gastroduodenostomy.     Button  passed  on  the  seventh  day. 
Discharged  November  30,  1897. 

Case  2. — Cancer  of  the  Pylorus;  Pylorectomy;  Partial  Gas- 
trectomy and  Gastroduodenostomy. — P.  D.,  female,  aged  fifty -four 
years;  admitted  to  St.  Mary's  Hospital  November  8,  1897,  with  a 
history  of  gastric  symptoms  extending  over  a  period  of  several 
months.  For  the  past  two  months  she  has  vomited  large  quan- 
tities of  partially  digested  or  decomposing  food  once  or  t^vice  in 
twenty-four  hours  and  has  grown  weaker,  with  a  loss  of  about  50 
pounds  in  weight. 

Physical  Exa?7iination. —Vatient  emaciated,  face  drawn  and 
haggard  in  appearance;  lungs  and  heart  in  good  condition;  urine 
contains  0.25  per  cent,  of  albumin,  no  casts.  A  large  quantity  of 
decomposing  food  material  was  removed  with  the  stomach-tube; 
through  the  tube  the  stomach  was  distended  with  air,  and  its 
lower  border  shown  to  be  three  inches  below  the  umbilicus.  An 
obscure  tumor  could  be  felt  in  the  epigastrium;  no  free  hydro- 
chloric acid  present  in  the  stomach-contents. 

Operation  November  25,  1897.  A  carcinomatous  stricture  of 
the  pylorus  was  found,  the  infiltration  extending  along  the  lesser 
curvature  to  a  point  three  inches  from  the  cardiac  orifice.  No 
apparent  glandular  enlargement.  Pylorectomy,  partial  gastrec- 
tomy (one-third  of  the  stomach)  and  gastroduodenostomy. 
Button  passed  on  the  sixteenth  day.  Discharged  December  23, 
1897. 

Case  3. — Cancer  of  the  Pylorus;  Pylorectomy  and  Gastro- 
duodenostomy.— M.  T..  male,  aged  forty-two  years;  admitted  to 
St.  Mary's  Hospital  January  3,  1898,  with  a  history  of  gradually 
increasing  stomach  trouble  during  the  past  three  years.  He  has 
been  unable  to  eat  solid  food  for  nine  months,  vomiting  the  greater 
part  of  the  nourishment  taken  at  irregular  intervals,  and  within  a 
month  has  had  two  attacks  of  apparent  complete  pyloric  obstruc- 
tion, each  lasting  three  or  four  days  and  accompanied  by  great 
prostration. 

Physical  Examination. — Patient  extremely  emaciated,  no 
tumor,  stomach  enormously  dilated  and  partly'  full,  the  lower 
border  apparently  resting  on  the  pelvic  brim;  no  free  hydro- 
chloric acid. 

Operation  January  5,  1898.  The  so-called  large  fibrinous  hy- 
pertrophy of  the  pylorus  was  found.     Obstruction  almost  com- 


MALHJNANT    OHSTUl(  TIO.N    OV    VM.OliVH  7J) 

plete.  Pylorectorny  and  ^astroduodenostomy.  It  was  noted 
after  the  anastomosis  was  effected  that  the  opening  was  rather  too 
close  to  the  suture  Hne,  hut  as  the  patient  was  in  a  had  condition, 
it  was  not  corrected.  Button  passed  on  the  twenty-first  day. 
Patient  cHscharf^od  January  'H,  1S9S.  Six  weeks  later,  having  up 
to  that  time  gained  3*2  pounds  in  weight,  he  was  seized  suddenly 
with  symptoms  of  acute  pyloric  obstruction.  His  condition  be- 
came worse  rapidly,  and  in  three  weeks  the  man  was  reduced  to  a 
remarkable  degree.  As  he  was  unable  to  return  to  the  hospital 
I  went  to  his  home,  where  I  found  him  confined  to  his  bed  and 
partly  delirious  from  starvation.  A  gastrojejunostomy  was  per- 
formed, but  no  attempt  was  made  to  ascertain  the  cause  of  the 
recent  obstruction  on  account  of  his  weak  condition.  For  two 
weeks  following  the  operation  the  patient  remained  in  a  precarious 
condition.  Then  his  recovery  was  rapid — in  two  months  he  had 
gained  42  pounds  and  he  is  now  apparently  well,  weighing  more 
than  ever  before. 

Case  4!.— Cancer  of  ihe  Pylorus;  Gastro-eyiterostomy. — A.  A., 
male,  aged  seventy  years;  admitted  to  St.  Mary's  Hospital 
August  2,  1894. 

Operation,  gastrojejunostomy  for  malignant  pyloric  obstruc- 
tion.    Death  on  the  fourteenth  day  from  aspiration  pneumonia. 

Postmortem  showed  complete  union;  button  in  the  stomach. 
Case  reported  in  "Annals  of  Surgery,"  1895. 

Case  5.— Cancer  of  the  Pylorus;  Gastro-enterostomy. — J.  K., 
male,  aged  fifty-eight  years;  admitted  to  St.  Mary's  Hospital 
March  5,  1895. 

Operation,  gastrojejunostomy  for  malignant  pyloric  obstruc- 
tion, March  8,  1895.  Button  passed  on  the  twentieth  day.  Dis- 
charged Api-il  5,  1895.  Remained  in  good  health  for  thirteen 
months,  then  died  from  rapid  return  of  the  disease. 

Case  6. — Cancer  of  Pylorus;  Gastro-enterostomy. — D.  D., 
male,  aged  sixty  years;  admitted  to  St.  Mary's  Hospital  June  30, 
1896. 

Operation,  gastrojejunostomy,  July  2,  1896,  for  obstructive 
cancer  of  pylorus.  Button  passed  the  eleventh  day.  Discharged 
July  18,  1896. 

Lived  for  more  than  one  year  in  comparative  comfort  before 
death  occurred  from  extension  of  the  disease. 


80  WILLIAM   J.    MAYO 

Case  1  .^Cancer  of  the  Pylorus;  Gastro-enterostomy. — M.  T., 
male,  aged  forty -two  years. 

Operation  February  26,  1898.  Gastrojejunostomy  for  acute 
pyloric  obstruction  six  weeks  after  pylorectomy  for  malignant 
disease.  (See  Case  3.)  Button  not  passed,  so  far  as  is  known. 
Patient  now  — three  months  after — has  gained  52  pounds  in  weight 
and  is  in  fine  condition. 

Discussion 
J.  B.  Murphy,  of  Chicago. — I  have  been  much  pleased  with 
the  emphasis  laid  by  the  essayist  upon  the  importance  of  early 
exploratory  operation  in  these  cases,  and  consider  this  one  of 
the  most  important  points  in  the  paper.  I  would  like  to  compli- 
ment the  author  upon  the  energetic  manner  with  which  he  has 
pursued  his  ideas.  I  have  made  a  number  of  exploratory  opera- 
tions in  order  to  determine  the  diagnosis.  If  we  are  to  have  good 
results  and  permanent  cures,  which  I  believe  we  should  have,  just 
as  in  the  cases  of  removal  of  the  cervix  for  carcinoma  in  the  early 
stage,  it  is  proper  to  make  an  early  exploratory  incision  for  the 
exposure  and  examination  of  the  pylorus,  a  procedure  involving  a 
risk  of  less  than  1  per  cent.  When  one  considers  the  number  of 
cases  that  occur  every  day  in  practice,  we  are  justified  in  taking 
these  chances,  and  the  time  will  come  when  we  will  be  obligated  to 
make  an  exploratory  incision,  and  not  allow  the  large  number  of 
cases  of  malignant  stenosis  of  the  pylorus  to  go  on  to  fatal  ter- 
mination, as  we  do  now.  The  method  of  drawing  forward  the 
pylorus  is  important,  and  enables  us  to  bring  it  immediately  out 
of  the  abdomen,  and  facilitates  the  operation.  Gastro-enterostomy 
has  become  a  well-recognized  procedure,  and  has  much  to  recom- 
mend it.  When  the  surgeon  performs  this  operation,  he  has 
rarely  seen  the  case  from  the  beginning,  and  when  a  medical  man 
refers  the  case  to  the  surgeon  for  gastro-enterostomy,  the  patient 
has  usually  been  allowed  to  pass  beyond  the  line  of  preservation 
of  his  life  and  is  sent  to  the  surgeon  for  operation,  so  that  he  may 
die  easy.  If  you  let  carcinoma  of  the  cervix  go  on  a  certain  time, 
hysterectomy  is  useless.  In  the  pylorus,  however,  a  longer  time 
usually  elapses  after  operation  before  secondary  infection  occurs. 


MAL1(;XANT    OBSTKL*  TION    Ol'    PYLORUS  81 

It  makes  l\\c  oljligaliori  to  operate  greater,  because  the  syniptoins 
exist  lor  a  more  protracted  period  and  \vc  should  not  he  coniiielled 
to  do  gastro-ontcrostoniy  at  such  hite  days. 

McAiiTUUR,  OF  Chicago. — We  might  reverse  tlic  method  in 
making  a  gastro-enterostomy  prior  to  the  removal  of  the  carcino- 
matous or  constricted  pylorus.  If  a  passage  were  to  be  provided 
prior  to  the  removal  of  the  pylorus,  the  patient  could  better  stand 
an  operation  later  for  removal  of  the  stomach. 

John  B.  Hamilton,  of  Chicago. — Three  years  ago  a  case 
came  under  my  observation,  when  I  acted  from  similar  motives 
to  those  contained  in  Mayo's  suggestion,  and  the  patient  is  still 
living.  She  was  at  the  time  thirty  years  of  age,  had  vomited, 
was  greatly  emaciated,  weighed  only  about  90  pounds,  and  could 
retain  nothing  in  the  stomach.  ^Malignant  disease  of  the  pylorus 
was  suspected,  but  no  hemorrhage  was  present;  an  exploratory 
incision  was  made.  When  I  opened  the  abdomen,  I  found  no 
glandular  involvement,  but  there  was  great  enlargement  of  the 
duodenum  at  the  pylorus.  I  opened  the  stomach  and  passed  my 
finger  into  the  pylorus  and  examined  it.  I  found  that  it  yielded 
to  finger  pressure,  and  then  inserted  one,  two,  and  three  fingers  so 
as  forcibly  to  dilate  it,  thus  performing  Loreta's  operation. 
Finding  that  I  now  had  a  free  opening  and  believing  the  case  to 
be  non-malignant,  I  closed  the  stomach  wound  in  the  ordinary 
manner.     The  woman  today  weighs  about  140  pounds. 


V(1L.   I fi 


THE   SURGICAL   TREATMENT   OF    DISEASES 
OF  THE  STOMACH* 

WILLIAM    J.    MAYO 


The  physician  who  keeps  in  touch  with  surgical  progress  will 
call  the  aid  of  the  surgeon  in  a  large  variety  of  gastric  ailments 
which  in  the  past  have  been  supposed  to  be  purely  medical  in 
character.  To  obtain  the  best  results  in  treatment  a  cordial  co- 
operation between  the  specialist  and  the  surgeon  is  desirable. 
That  this  cooperation  is  not  now  practised  must  be  admitted,  and 
many  sufferers  amenable  to  surgical  relief  are  dragging  out  a 
miserable  existence  with  symptoms  which,  if  located  in  the  region 
of  the  pelvis,  appendix,  or  gall-bladder,  would  demand  prompt 
attention. 

From  an  operative  point  of  view  the  stomach  is  a  favorable 
organ  upon  which  to  work — far  more  so  than  the  intestines.  Its 
abundant  blood-supply  is  derived  from  several  independent 
sources,  so  that  incisions  of  almost  any  extent  may  be  expected  to 
heal.  Its  mucous  coat  is  very  thick  and  easily  separated  from  the 
muscular  and  peritoneal  coats,  permitting  of  easy  suture,  and  the 
gastric  juices,  while  not  germicidal,  are  hostile  to  the  growth  of 
bacteria.  Gushing  demonstrated  experimentally  that  the  con- 
tents of  the  upper  portion  of  the  alimentary  canal  were  far  less 
septic  than  in  the  lower  ileum,  or  large  bowel,  and  clinical  experi- 
ence proves  that  gunshot  wounds  of  the  upper  part  of  the  intes- 
tinal tract  most  often  do  well  after  operative  interference. 

The  somewhat  fixed  position  of  the  stomach  favors  the  locali- 
zation, by  adhesions,  of  gastric  perforations,  in  marked  contrast 

*  Reprinted  from  the  special  number  on  Gastric  Diseases,  "Philadelphia 
Medical  Journal,"  February  3,  1900. 


srU(;i(  AL    TREATMENT    OF    DISEASES   OF   STOMACH  83 

willi  rai)i(l  dissemination  through  siiuihir  lesions  in  the  intestinal 
wall.  Tlie  iiMfa\()ral)le  feature  of  such  j)erforations  lies  more  in 
the  large  (juantity  of  material  which  the  stomaeh  may  contain 
than  in  its  virulent  character. 

An  operative  experience  thus  far  in  this  branch  of  surgery  com- 
prises about  60  cases — not  enough  to  establish  any  definite  con- 
clusions, yet  sufficient  to  be  suggestive  as  to  certain  details  of  the 
work. 

Fifty-three  of  these  cases  were  operated  upon  in  St.  Mary's 
Hospital  during  the  past  six  years,  and  as  these  patients  have 
been  under  personal  observation  and  the  after-results  are  known, 
the  data  will  be  used  in  this  paper  to  the  exclusion  of  the  cases 
operated  upon  in  other  institutions  or  in  private  houses,  under 
circumstances  in  which  the  conditions  were  less  uniform. 

Malignant  Disease 

Exploratory 10 

Pylorcctoniy  with  gastroduodenostomy 3 

Gastro-entcrostomy 8 

Gastrostomy 2 

A  total  of  '23  cases  with  4  deaths.  The  cause  of  death  in  2  was 
aspiration  pneumonia,  and  2  occurred  from  a  form  of  exhaustion 
often  seen  after  abdominal  operation  for  malignant  disease,  due  to 
a  sudden  failure  of  the  vital  forces  coming  on  about  the  fifth  day. 

\ON-MALIGNANT    DiSEASE 

(iastro-enterostoniy 15 

Gastrostomy 3 

Pyloroplasty 8 

Adhesions  the  result  of  healed  ulcer  of  the  duodenum 1 

Adhesions  from  pistric  ulcer 1 

Adhesions  to  gall-bladder 1 

Gastrorrhaphy  for  gunshot  woimtl 1 

A  total  of  30  cases,  with  1  death  from  exhaustion  on  the  eighth 
day  after  a  gastro-enterostomy  in  an  extremely  emaciated  man 
fifty  years  of  age. 

The  anesthetic  and  its  methoil  of  giving  are  important  factors 
in  the  result,  as  will  be  easily  imderstood  from  the  high  percent- 
age of  deaths  from  aspiration  pneumonia;   all  in  all,  we  have  been 


84  WILLIAM   J.    MAYO 

best  pleased  with  a  preliminary  hypodermic  injection  of  morphin, 
followed  by  chloroform  anesthesia,  and  in  exhausted  patients 
only  enough  of  the  latter  is  used  to  produce  insensibility  during 
the  incision  of  the  abdominal  walls,  and  again  in  closing.  There 
is  no  pain  during  the  work  on  the  stomach.  Cocain  anesthesia 
has  been  successfully  used  in  a  number  of  such  cases.  If  the  stom- 
ach is  greatly  dilated  and  contains  a  quantity  of  fluid,  not  always 
so  fully  removed  by  preliminary  siphonage  as  one  expects,  care 
should  be  used  in  elevating  the  organ  out  of  the  incision  to  prevent 
drowning  the  patient  with  its  contents.  The  inhalation  pneumonia 
which  occurred  in  our  cases  was  due,  I  believe,  to  raising  the 
stomach  to  such  an  extent  as  to  allow  some  of  its  contents  to  pass 
into  the  esophagus  and  trachea. 

Explorations. — My  experience  leads  me  to  believe  that  in  the 
beginning  the  operation  is  necessarily  exploratory  in  character, 
for  the  most  skilled  diagnostician  may  fail  to  make  an  accurate 
diagnosis  without  incision,  and  even  after  opening  the  abdomen  it 
is  not  so  easy  as  it  might  appear  to  the  uninitiated  to  ascertain  the 
condition.  This  is  particularly  true  of  malignant  disease,  an  early 
exploration  being  the  only  way  of  ascertaining  the  condition  in 
time  to  be  of  any  service.  It  will  be  noted  that  no  less  than  10  of 
our  operations  were  explorations.  Our  only  regret  is  that  they 
were  not  made  earlier. 

For  most  purposes  the  median  incision,  half  way  between  the 
umbilicus  and  the  xiphoid  cartilage,  will  be  found  the  most  con- 
venient; on  its  right  side  is  the  suspensory  ligament  of  the  liver, 
often  confusing  to  one  who  is  not  expecting  it.  Normally,  the 
pylorus  will  lie  just  underneath  or  a  little  to  the  right.  If  obstruc- 
tion exists  at  the  cardia,  the  stomach  will  be  collapsed  to  a  remark- 
able degree  and  lie  behind  the  left  lobe  of  the  liver;  on  the  con- 
trary, if  the  pylorus  be  obstructed,  the  dilated  organ  may  fill  two- 
thirds  of  the  abdominal  cavity.  Should  there  be  a  tumor  in  the 
pylorus,  it  would  sag  downward  and  to  the  right,  and  if  the  tumor 
be  malignant,  enlarged  and  tortuous  blood-vessels  will  be  seen 
underneath  the  peritoneum;  the  hard,  nodular  "feel "  of  the  growtli 
will  also  aid  in  establishing  the  diagnosis. 


SURGICAL    TREATMKNT    OF    I)ISEASp:S    OF    STOMACH  S.5 

As  a  rule,  malignant  disease  ends  sliarj)ly  at  llie  duodenum, 
which  is  seldom  involved,  the  extension  bein^i;  along  the  stomach- 
wall.  Ulcerative  conditions  often  show  board-like  scars  with 
lesseiied  vascularity  and  are  more  often  adherent  than  in  malig- 
nant disease. 

Mikulicz  says  the  lymphatic  glands  lie  in  four  groups:  (1)  Along 
the  lesser  curvature  and  cardia;  (!2)  along  the  greater  curvature; 
(3)  in  the  gastrocolic  omentum;  (4)  about  the  head  of  the  pancreas. 

In  previous  communications  on  the  subject  I  have  called  at- 
tention to  the  frequency  with  wliich  enlarged  glands  are  found  in 
non-malignant  disease,  especially  so  in  ulceration  and  chronic 
obstruction;  too  much  significance  should  not  be  placed  on  this 
enlargement,  as  in  these  cases  it  is  due  to  sepsis. 

To  further  the  exploration,  the  gastrohepatic  omentum  may  be 
partially  divided,  and  after  this  the  pylorus  can  be  mobilized  and 
drawn  from  the  abdomen  for  more  careful  examination  without 
interfering  with  its  blood-  or  nerve-supply. 

Incisions  into  the  cavity  of  the  stomach  are  often  necessary  to 
expose  a  perforation  or  locate  a  foreign  body. 

To  explore  the  cardiac  orifice,  or  for  retrograde  dilatation  of 
the  esophagus,  Richardson  directs  that  the  lesser  curvature  be 
held  taut  and  the  exploring  instruments  in  the  stomach  be  carried 
along  the  sulcus  thus  produced  to  the  opening.  Abbe  says  that 
often  the  closure  of  the  cardiac  orifice  is  so  perfect  that  only  after 
steady  pressure  of  a  little  duration  will  a  dimple  be  felt  correspond- 
ing to  the  esophageal  opening. 

For  various  reasons,  such  as  the  feeble  condition  of  the  patient 
or  the  inaccessible  situation  of  the  disease,  a  complete  diagnosis 
cannot  be  made,  yet  if  symptomatic  indications  exist,  operative 
relief  should  be  afforded  notwithstanding.  This  will  often  happen 
in  obstructions  at  the  cardiac  orifice,  and  occasionally  at  the  py- 
lorus, calling  for  a  gastrostomy.  In  one  instance  we  were  unable 
to  examine  an  obstruction  which  was  known  to  exist  at  the  pyloric 
opening,  the  latter  being  displaced  high  up  under  the  liver  and  very 
adherent.  A  gastro-enterostomy  was  followed  by  complete  re- 
covery, the  patient  being  nlive  and  well  three  years  later. 


86  WILLIAM   J.    MAYO 

On  the  other  hand,  the  mahgnant  nature  of  the  disease  may 
be  plainly  hopeless  in  its  extent,  yet  not  produce  obstructive  symp- 
toms ;  under  these  circumstances  the  incision  should  be  closed  in  a 
manner  which  will  give  as  little  discomfort  as  possible.  For  this 
purpose  permanent  buried  sutures  of  silver  wire,  silkworm  gut,  or 
silk  will  enable  the  patient  to  get  about  in  a  few  days  and  leave  the 
hospital  within  a  week.  Many  of  these  patients,  if  kept  in  bed 
the  usual  time,  will  develop  hypostatic  congestions,  and  too  often 
never  leave  the  hospital  alive. 

Sutures  buried  in  the  upper  median  line  seldom  give  after- 
trouble,  as  they  are  encapsulated  in  fixed  aponeurotic  structures. 
If  placed  in  muscle  or  other  movable  tissues,  atrophy  necrosis  may 
follow,  necessitating  removal.  In  any  case  the  hernia  liability  is 
of  small  importance  to  the  victim  of  a  progressive  malignant  dis- 
ease. 

New-growths 

Carcinoma  of  the  stomach  occurs  in  35  per  cent,  of  all  cases  of 
cancer  (Richardson),  and  while  it  may  exist  in  any  variety,  the 
scirrhous  form  is  by  far  the  most  common.  Sarcoma  and  benign 
growths  have  been  recorded,  though  rarely. 

Gastrectomy  or  complete  removal  of  the  stomach  was  first 
performed  in  this  country  by  Conner,  of  Cincinnati,  and  second 
by  Baldy,  of  Philadelphia,  both  unsuccessfully.  Schlatter's  cele- 
brated case  first  brought  general  attention  to  the  subject,  and  many 
cases  are  now  recorded,  the  most  noteworthy  successes  being  those 
of  Macdonald,  of  San  Francisco,  of  Richardson,  of  Boston,  and 
Brigham,  of  San  Francisco.  The  most  favorable  form  of  malig- 
nant disease  for  this  operation  is  the  pathologic  condition  long 
called  "cirrhosis"  of  the  stomach,  marked  by  enormous  thicken- 
ing of  the  wall  without  dilatation, — like  an  india-rubber  water 
bottle  (Bristow), — a  chronic  process,  as  one  would  expect  from  the 
great  amount  of  connective-tissue  formation  and  the  sparseness 
of  the  carcinoma  cells. 

Carcinoma  of  the  pylorus  forms  60  per  cent,  of  the  gastric 
cancers,  and  a  sufficient  number  of  successful  pylorectomies  have 
passed  the  three-year-limit  to  give  the  operation  a  standing  in 
surgery. 


SURGICAL   TREATMENT    OF    DISEASKS    OF    STOMACH  S7 

We  have  developed  a  melliod  of  perfoniiin^  pylorectomy  and 
partial  gastreetomy  which  in  three  cases  proved  to  be  a  rapid  and 
comparatively  safe  procedure.* 

1.  A  median  incision  ahove  the  umhilictis  and,  if  needed,  a 
cross-cut  of  the  rectus  nnisclc. 

2.  Double  ligation  and  division  of  the  necessary  amount  of 
gastrohej)atic  omentum;  this  allows  the  pylorus  and  lesser  curva- 
ture to  be  delivered.  The  fingers  are  now  in  the  lesser  cavity  of 
the  peritoneum,  and  at  once  slip  under  the  pylorus,  acting  as  a 
guide  to  the  careful  double  ligation  and  division  of  the  gastrocolic 
omentum  attached  to  the  malignant  area. 

3.  The  diseased  part  is  isolated  by  a  piece  of  gauze  drawn  under 
it,  and  a  pair  of  forceps  are  caught  from  each  side,  separating  the 
diseased  from  the  healthy  stomach  and  also  preventing  leakage 
from  below.  With  a  knife  a  circular  cut  is  made  completely 
around  the  health}^  portion  of  the  stomach  to  the  mucous  coat. 
The  muscular  and  peritoneal  coats  are  stripped  back,  and  a  few 
bleeding  points  caught  with  forceps.  The  mucous  coat  is  cut 
inch  by  inch  and  closed  with  the  continuous  suture;  this  is  cut 
short,  and  the  detached  j)yIorus  and  tumor  are  covered  and  turned 
out  of  the  way.  A  second  continuous  catgut  suture  of  the  mus- 
cular coat  rolls  in  the  mucous  layer,  while  outside  of  this  a  good 
silk  Lembert  of  the  peritoneum  and  muscular  coats  protects  and 
rolls  in  the  two  first  rows  of  sutures. 

4.  The  end  of  the  stomach  is  slipped  to  the  right,  and  the  ends 
of  the  tied  omentum  are  sutured  to  each  other  and  to  the  suture 
line,  not  only  making  further  protection,  but  also  anchoring  the 
stomach  to  the  right  and  preventing  undue  traction  upon  the  duo- 
denum after  it  is  fastened  in  place. 

5.  The  duodenum  is  cleanly  amputated  at  a  healthy  point  and 
l)uttoned  with  a  Murphy  button  to  the  anterior  wall  of  the  stomach. 
,  The  most  favorable  cases  for  pylorectomy  are  those  in  which 
early  obstruction  leads  to  early  operation. 

*  Note  previously  published  in  "Xew  York  Medical  Record,"  June  11,  1898. 


88  william  j.  mayo 

Ulcers 

Syphilitic  and  tuberculous  ulcerations  of  the  stomach  occur, 
but  so  rarely  as  to  be  of  Uttle  moment  to  us  in  this  resume.  Ulcer- 
ation of  this  organ  is  of  the  simple  variety,  and  in  no  department 
of  surgery  has  there  been,  recently,  so  great  an  advance  as  in  the 
operative  relief  of  this  distressing  and  dangerous  malady.  It 
may  be  said  that  prolonged  and  unsuccessful  medical  treatment 
of  this  condition  is  not  for  the  best  interests  of  the  patient. 

Gerhardt  states  that  28  per  cent,  of  the  cases  of  gastric  ulcer 
treated  medically  eventually  prove  fatal.  Leube,  of  Wtirzburg, 
in  the  tabulation  of  1000  cases  of  gastric  ulcer,  gives  a  direct  mor- 
tality of  4  per  cent,  from  hemorrhage  or  perforation,  and  21  per 
cent,  were  not  cured.  It  is  probable  that  about  75  per  cent,  can 
be  cured  by  medical  and  dietetic  treatment  in  four  or  five  weeks. 
Heydenreich  gives  the  mortality  of  pylorectomy  at  27  per  cent., 
gastro-enterostomy,  16  per  cent.,  and  pyloroplasty,  13  per  cent. 

It  may  be  said  that  85  per  cent,  of  the  cases  which  cannot  be 
cured  by  medical  treatment  can  be  cured  by  operation.  In  this 
connection  the  recent  reports  of  the  cases  of  gastric  ulcer  treated 
in  the  Massachusetts  General  Hospital  are  of  great  interest. 

For  chronic  intractable  ulceration  three  methods  of  operation 
have  been  practised— excision,  incision  with  suture,  and  gastro- 
enterostomy— each  has  its  proper  indication  and  field  of  usefulness. 

Nicolaysen  has  gathered  30  cases  from  the  literature  success- 
fully treated  by  gastro-enterostomy.  In  two  cases  of  our  own  the 
results  of  gastro-enterostomy  for  the  relief  of  open  ulcers  were 
very  satisfactory. 

Thirteen  per  cent,  of  all  gastric  ulcers  perforate  (Micheaux). 
Of  56  cases  of  perforations  collected  by  Dickinson  from  the  St. 
George's  Hospital  reports,  about  one-half  died  at  once  and  the  other 
half  had  adhesions,  with  resulting  abdominal  or  subphrenic  abscess, 
fistula,  or  other  secondary  complications.  The  result  depends  on 
the  suddenness  of  the  perforation,  its  location,  and  the  amount  of 
the  gastric  contents  at  the  time,  those  on  the  lesser  curvature  and 
posterior  surface  being  more  liable  to  be  at  least  temporarily  pro- 


SURGICAL    THKATMKN'r    OK    I)1.S1:asp:.S    OK    STOMACH  S!) 

tectetl  hy  adlR'sious.  In  ?!);{  perforaLcd  cases  Wulcli  fcjund  Vri 
per  cent,  on  the  lesser  curvalurc  and  the  posterior  wall. 

The  treatment  of  acute  perforation  is  immediate  suture  with 
an  omental  graft,  or,  if  necessary,  gauze  isolation  and  drainage. 
Secondary  processes,  the  result  of  perforations,  should  be  cared 
for  on  ordinary  surgical  principles.  Keen  has  collected  156  cases 
of  perforation  which  have  been  operated  upon  with  encouraging 
success. 

Hemorrhage,  the  result  of  gastric  ulcer,  has  been  treated  by 
KUster  and  others  by  primary  incision,  or  with  the  actual  cautery 
and  gastro-enterostomy.  In  the  October  number  of  the  "Annals 
of  Surgery,"  1899,  Andrews  and  Eisendrath  have  reported  a 
definite  operation  for  the  treatment  of  hemorrhage  from  gastric 
ulcer  which  promises  well. 

Chronic  distress,  the  result  of  adhesions  connecting  a  healed 
gastric  ulcer  to  a  neighboring  organ,  is  one  of  the  common  sequels, 
a  condition  which  may  be  readily  relieved  by  dividing  the  connect- 
ing bands. 

The  most  common  after-result  of  the  healing  process  is  dis- 
tortion and  contraction,  commonly  at  the  pyloric  opening,  rarely 
in  the  body  of  the  stomach,  producing  an  hour-glass  contraction. 
This  brings  us  to  the  surgical  treatment  of  the  obstructions  without 
regard  to  their  origin. 

Obstructions 

Obstruction  of  the  cardiac  orifice  preventing  proper  feeding 
demands  gastrostomy.  A  curved  abdominal  incision  to  the  left 
of  the  median  line  will  be  found  most  suitable  for  this  purpose. 
The  form  of  operation  depends  on  the  indications;  for  temporary 
feeding  purposes  the  Witzel  operation  is  very  satisfactory. 

A  rubber  tube  the  size  of  a  lead-pencil  is  inserted  through  an 
opening  in  the  stomach-wall  and  inclosed  by  a  lateral  fold  of  the 
peritoneal  and  muscular  coats.  It  does  not  leak,  and  on  removal 
of  the  tube  the  opening  heals  at  once.  The  disadvantage  is  that 
if  further  exploration  of  the  interior  of  the  stomach  is  desired,  the 
obliquity  of  the  canal  is  an  awkward  feature;   for  this  reason  the 


90  WILLIAJVI   J.    MAYO 

operation  of  Kader  may  be  preferred;  like  the  Witzel  plan,  a 
rubber  tube  is  inserted  and  held  by  a  catgut  suture.  A  fold  of  the 
peritoneal  and  muscular  coats  is  caught  each  side  of  the  tube  with 
sutures  and  tied;  this  is  repeated  several  times  until  a  cone  or 
nipple-like  projection  is  caused  to  present  directly  into  the  gastric 
ca\dty.  Bernays  modifies  this  by  using  a  circular  suture  of  cat- 
gut for  the  same  purpose. 

For  permanent  feeding  the  Ssabanejew-Frank  operation  has 
no  peer;  unhke  those  mentioned  above,  it  does  not  need  a  tube,  and 
the  fistula  formed  is  a  mucocutaneous  one,  with  no  tendency  to 
contraction  of  the  orifice.  A  fold  of  the  stomach- wall  is  drawn 
through  the  abdominal  incision  and  the  base  sutured  to  the  mus- 
cular and  aponeurotic  coats. 

A  second  cutaneous  incision  is  made  an  inch  above  the  first, 
and  to  the  left  the  intervening  bridge  of  skin  is  undermined.  The 
apex  of  the  protruding  cone  of  stomach  is  sutured  to  the  margins 
of  the  upper  incision,  forming  a  spout-like  opening. 

Hour-glass  contractions  of  the  body  of  the  stomach  can  be 
treated  by  incision  and  suture  for  gastro-enterostomy,  attaching 
the  jejunum  to  the  proximal  pouch. 

Pyloric  Obstruction 

It  has  been  noted  that  with  the  same  amount  of  mechanical 
obstruction  the  sj^mptoms  vary  mth  the  position  of  the  pylorus. 
If  the  pylorus  lies  low  down,  gravity  aids  the  stomach  in  getting 
rid  of  its  contents;  if  it  occupies  a  high  position  with  a  short  gas- 
trohepatic  omentum,  emptying  the  stomach  depends  entirely  on 
muscular  effort,  and  in  the  latter  instance  dilatation  and  its  train 
of  distressing  symptoms  come  on  much  earlier. 

In  a  paper  read  before  the  American  Medical  Association  in 
1896  I  called  attention  to  a  phenomenon  observed  in  these  cases, — 
a  valve  formation, — which  results  from  a  high-lying  pylorus  with 
a  moderate  amount  of  obstruction  of  any  form.  The  constant 
effort  of  the  stomach  to  elevate  its  contents  causes  hypertrophy  of 
the  walls  and  secondary  dilatation  with  chronic  gastric  distress 
and  occasional  vomiting  of  large  amounts  of  material.     In  other 


SURGICAL   TREATMi:Nr    OF    DISKASKS   OF   STOMAril  !)1 

words,  overloading  the  stomach  (•oni[)resses  the  pylorus  and  j>re- 
vcnts  egress  of  the  food.  The  condition  is  similar  to  that  of  valve 
formation  of  the  nn'ter  at  the  pelvis  of  the  kidneys,  described  by 
Christian  Fenger  as  intermittent  hydronephrosis  and  pyonephrosis. 
(Jastroptosis  may  act  in  a  .similar  manner,  causing  chronic  indiges- 
tion and  distress. 

In  the  relief  of  pyloric  obstruction  gastro-enterostomy  plays 
the  most  prominent  part,  and  but  two  methods  have  won  recogni- 
tion— the  simple  suture  plan  and  the  Murphy  button.  The  ad- 
vocates are  rather  equally  divided;  for  example,  Kocher,  Doyen, 
and  Senn  use  the  suture,  Czerny,  Kiimmell,  and  a  large  share  of 
the  German  surgeons  hold  to  the  button. 

We  have  used  the  button  exclusively  in  the  cases  operated 
upon,  and  either  the  recovery  of  the  patient  or  the  postmortem 
has  established,  the  competency  of  the  device.  Unfortunate 
button,  experience  drawn  from  cases  of  acute  intestinal  obstruc- 
tion will  not  hold  good  in  these  cases,  as  at  the  point  of  attachment 
both  the  stomach  and  the  intestine  are  healthy,  while  in  the  former 
ease  the  proximal  portion  of  the  bowel  is  usually  congested  for  a 
great  distance.  To  set  up  a  sloughing  process  in  damaged  tissues 
is  not  good  surgery,  as  the  chances  are  that  it  will  not  limit  itself 
and  perforation  often  occurs;   the  suture  is  safer  in  these  cases. 

As  to  whether  the  anastomosis  between  the  stomach  and  je- 
junum shall  be  made  on  the  anterior  or  the  posterior  wall  of  the 
stomach,  there  is  also  a  difference  of  opinion. 

All  our  cases  have  been  anterior  operations,  and  we  see  no 
reason  to  regret  it.  The  posterior  method  requires  a  larger  in- 
cision, more  manipulation,  and  also  creates  an  artificial  defect  in 
the  transverse  mesocolon  to  get  into  the  lesser  cavity  of  the  peri- 
toneum. I  do  not  believe  that  these  disadvantages  are  counter- 
balanced by  any  practical  results  to  the  patient. 

In  using  the  button,  grasp  the  jejunum  at  its  origin,  form  a  coil 
of  about  14.  inches  in  length,  and  introduce  the  male  half  into  the 
intestine  first.  In  placing  the  female  half  in  the  stomach-wall,  cut 
through  the  muscular  and  peritoneal  coats  before  introducing  the 
suture,  and  keep  close  to  the  margin  of  this  incision  with  it;   other- 


92  WILLIAM   J.    MAYO 

wise  the  thick  coats  ruffle  up  and  prevent  easy  approximation. 
Unite  so  that  intestinal  and  gastric  peristalsis  will  be  in  the  same 
line.  If  the  union  is  nicely  done,  the  anterior  wall  of  the  stomach 
will  tip  downward  and  form  a  funnel  at  the  point  of  union. 

Malthe  says  that  if  after  the  approximation  the  button  lies  to 
the  right  of  the  spinal  column,  it  will  go  down — if  to  the  left  it  will 
drop  back  into  the  stomach;  it  does  not  seem  to  make  much  differ- 
ence whether  the  button  passes  out  or  drops  back;  in  the  latter 
event,  no  harmful  results  have  been  reported.  Some  of  our  cases 
of  button  gastro-enterostomy  have  already  gone  from  three  to 
six  years  since  operation  and  remain  in  perfect  health,  although  in 
several  of  these  cases  the  button  has  never  been  passed  to  our 
knowledge. 

The  pyloroplasty  of  Heineke-Mikulicz,  which  consists  in  mak- 
ing a  longitudinal  incision  two  or  three  inches  in  length,  with  its 
center  at  the  stricture,  and  suturing  the  wound  transversely,  is  an 
operation  which  is  not  so  popular  as  it  was  formerly,  and  many 
surgeons  have  substituted  gastro-enterostomy  for  it  in  every  case. 
We  had  relapse  follow  the  operation  in  two  cases ;  in  each  instance 
at  the  secondary  operation  the  pylorus  lay  very  high  and  was  ad- 
herent, with  evident  valve  formation. 

Reasoning  that  gastro-enterostomy  succeeded  because  gravity 
emptied  the  stomach  through  the  dependent  opening,  we  have,  in 
three  cases,  pushed  the  pylorus  downward  and  fastened  it  in  this 
pos'tion  by  a  suture  to  the  abdominal  wall.  The  results  thus  far 
have  been  excellent. 

The  gastroplication  of  Bircher  and  the  gastropexy  of  Duret 
have  little  to  recommend  them,  while  the  dilatation  of  Loreta  is 
an  obsolete  operation. 

Traumatisms  of  the  stomach  are  so  purely  surgical  that  I  will 
not  take  up  time  further  than  to  say  that  the  results  of  the  applica- 
tion of  modern  surgical  principles  to  these  injuries  have  been  most 
satisfactory. 


MALIGNANT    DISEASES    OF    THE    STOMACH 
AND  PYLORUS* 

WILLIAM    J.    MAYO 

Carcinoma  of  the  stomach  causes  about  1  per  cent,  of  the  total 
death-rate  (Van  Valzah),  and  is  the  most  common  form  of  mahg- 
nant  disease.  In  an  analysis  of  30,000  cases  of  malignant  neo- 
plasms Welch  gives  the  percentage  as  21.4;  Virchow,  3o,  and 
Haberlin,  as  41.5  per  cent. 

Age  has  a  more  important  bearing  on  carcinoma  of  the  stom- 
ach than  on  carcinoma  of  the  lower  portion  of  the  gastro-intestinal 
tract.  In  the  former  locality  it  is  peculiarly  a  disease  of  middle 
and  later  life;  it  is  most  rare  under  thirty  years  of  age,  although 
Moore  reports  a  case  at  the  age  of  thirteen.  It  is  slightly  more 
frequent  in  males  than  in  females — 5  to  4  (Welch);  the  dispro- 
portion, however,  is  not  so  great  as  the  older  authorities  were  in- 
clined to  believe. 

The  progress  of  the  disease  varies,  and  is  materially  aflFected 
by  the  age  of  the  patient,  the  situation  of  the  growth,  and  its 
histologic  structure.  Death  may  follow  in  three  months  from  the 
first  symptoms,  or  it  may  be  delayed  to  two  and  one-half  years; 
the  majority  of  patients  die  within  the  year.  Park  is  of  the  opin- 
ion that  all  forms  of  malignant  tumors  are  on  the  increase;  how 
nuich  of  this  increase  is  apparent  rather  than  real  and  due  to  better 
methods  of  diagnosis  is  open  to  discussion. 

Surgery  oflfers  the  only  hope  of  cure:  it  is  important  that  car- 
cinoma of  the  stomach  be  considered  a  surgical  disease,  and  a  sus- 
picion of  gastric  cancer  should  cause  the  physician  to  send  the 
patient  to  the  surgeon  for  exploratory  incision  to  complete  the 

*Rcprintoil  from  '"Trans.  Amor.  Surg.  .Vssor.,"  IHOO. 
93 


94  WILLIAM   J.    MAYO 

examination.  The  same  principles  should  govern  here  as  in  prob- 
able malignant  disease  of  the  breast  or  uterus.  The  great  difficulty 
which  arises  in  carrying  this  proposition  into  eflFect  is  the  question 
of  early  diagnosis.  In  a  general  way  it  can  be  said  that  the  early 
medical  diagnosis  of  cancer  of  the  stomach  does  not  depend  upon 
any  one  specific  sign  or  symptom,  but  rather  on  a  collection  of 
facts,  each  one  of  which,  if  taken  alone,  would  have  but  little  value; 
and,  again,  most  of  these  symptoms  are  not  developed  to  a  char- 
acteristic extent  until  late.  Osier  reports  a  number  of  cases  of 
latent  cancer  of  the  stomach  in  which  there  were  no  symptoms 
during  life  to  lead  to  a  suspicion  of  malignant  disease,  the  true 
condition  being  found  at  postmortem. 

A  person  of  middle  or  advanced  life,  of  previous  good  digestive 
power,  begins  to  complain  of  pain  in  the  region  of  the  stomach, 
difficult  digestion,  and  loss  of  appetite.  There  is  a  continuous 
loss  of  flesh;  a  progressive  waste  of  the  albuminous  tissues;  later 
there  is  more  or  less  vomiting,  depending  on  the  situation  of  the 
growth,  perhaps  of  blood  partially  digested  and  likened  to  coffee- 
grounds.  A  tumor  may  gradually  become  discernible  (115  out  of 
150  causes.  Osier).  A  dry  cachexia  develops,  and  transitory  edema, 
usually  affecting  the  lower  limbs  and  due  to  a  local  phlebitis,  may 
occur.  This  seems  to  be  a  clear  clinical  picture  of  malignant 
disease,  but  the  fault  is  that,  sui-gically  speaking,  the  case  has  been 
hopeless  since  the  first  few  weeks.  Czerny,  Kraske,  and  many 
other  eminent  authorities  believe  that  radical  operation  is  out  of 
the  question  by  the  time  a  tumor  can  be  felt. 

Examination  by  means  of  stomach-tests  adds  to  our  diagnostic 
resources.  The  absence  of  free  hydrochloric  acid  is  an  indication 
of  value,  and  it  occurs  in  60  per  cent,  of  all  cases,  but  is  not  always 
well  marked  early.  In  the  forms  of  malignant  disease  developing 
upon  ulcer,  of  which  a  number  had  been  collected  and  described 
by  Hemmeter,  the  free  hydrochloric  acid  may  even  be  increased. 
Another  valuable  indication  is  the  presence  of  lactic  acid  accom- 
panied by  the  Oppler-Boas  bacillus. 

Reduced  motor  power  of  the  stomach  independent  of  obstruc- 
tion is  a  constant  symptom,  but  is  also  common  to  non-malig- 


MALKiNANT    DISKASKS    OK    ST()MA(  M    AVI)    I'VLORUS  *.l) 

iiiint  disease,  such  as  gastric  myasthenia.  Terrier,  in  his  recciif 
work  on  surgery  of  the  stomach,  says  tliat  "the  examination  of 
a  fasting  stomach  gives  the  largest  amount  of  information.  " 
The  only  positive  diagnostic  indication  is  the  finding  of  cancer 
elements  in  the  fragments  wa.shed  out  of  the  stomach;  here 
again,  unfortunately,  the  spontaneous  detachment  of  such  speci- 
mens in  an  early  stage  of  the  disease  must  necessarily  be  a  very 
rare  occurrence.  The  value,  however,  is  absolute,  and  efforts 
in  this  direction  are  increasing.  In  the  laboratory  of  Boas  the 
first  systematic  efforts  to  detach  pieces  of  the  growth  for  this 
purpose  were  made.  To  locate  the  point  from  which  the  pieces 
are  detached  Kuhn  invented  a  spiral  sound  which  could  be  watched 
with  the  j-ray.  Hemmeter  has  systematically  developed  this 
method  of  examination,  both  in  the  means  of  detaching  the  frag- 
ments and  in  the  certainty  as  to  the  location  of  their  origin,  the 
examination  being  conducted  after  the  manner  of  uterine  scrapings. 
He  calls  especial  attention  to  the  diagnostic  importance  of  atypical 
as  well  as  pathologic  mitoses  of  the  cells. 

One  important  point  is  to  be  determined:  Is  there  danger  of 
increasing  the  spread  of  the  disease  by  diagnostic  cureting?  The 
removal  of  pieces  of  malignant  growth  for  microscopic  examina- 
tion is  a  doubtful  practice.  Senn  warns  against  the  rough  hand- 
ling of  a  malignant  tumor  for  the  purpose  of  making  a  diagnosis, 
and  says  that  such  "diagnostic  massage"  may  result  in  increased 
activity.  Halsted  opposes  the  removal  of  portions  of  a  malignant 
growth  for  diagnostic  purposes  on  account  of  the  danger  of  inocu- 
lation. Whether  this  objection  would  hold  good  in  the  necessary 
manipulations  for  the  removal  of  fragments  from  a  gastric  cancer 
is  worthy  of  consideration. 

Examination  of  the  blood  shows  reduced  specific  gravity,  di- 
minished hemoglobin  and  number  of  the  red  corpuscles,  and  re- 
duction in  their  size;  these  changes  are  due  to  the  anemia  and  have 
no  special  characteristic  in  malignant  disease  of  the  stomach.  The 
white  corpuscles  are  often  increased  by  the  accompanying  inflam- 
mation and  ulceration.  The  urinary  changes  are  in  no  way  pecu- 
liar to  the  cancerous  process.     The  indican,  so  frequent  an  accom- 


96  WILLIAM   J.    MAYO 

paniment,  is  the  result  of  the  retention,  and  the  other  changes  to 
the  albuminous  waste  and  low  state  of  the  nutrition. 

Van  Valzah  says  that  careful  and  repeated  examination  of  a 
suspicious  case  of  carcinoma  of  the  stomach  should  develop  a 
probable  diagnosis  in  two  or  three  weeks. 

The  scientific  zeal  with  which  the  diagnosis  is  sought  has  in 
itself  a  distinct  danger.  The  suspicious  case  is  often  kept  under 
observation  too  long  in  the  hope  of  making  a  positive  diagnosis. 
The  surgeon  should  not  ask  the  physician  for  a  diagnosis  of  gastric 
cancer;  if  we  wait  for  that  we  are  pretty  sure  of  being  too  late. 
It  is  the  suspicious  cases  which  should  be  explored,  and  it  is  the 
duty  of  the  physician  to  urge  this  when  in  doubt.  A  few  indica- 
tions, with  the  history,  should  suffice,  and  the  matter  laid  before 
the  patient  to  decide  as  to  an  exploration. 

There  is  no  reason  why  the  radical  cure  of  cancer  of  the  stomach 
should  not  approach  that  of  the  uterus  or  breast.  It  is  true,  the 
difficulties  of  diagnosis  are  increased,  yet  the  early  symptoms 
are  quite  as  positive.  At  an  early  stage  the  tumor  in  the  breast  is 
unnoticed  or  no  attention  is  paid  to  it,  and  the  early  history  of 
cancer  of  the  uterus  is  notoriously  defective,  with  the  result  that 
the  number  of  cures  in  either  breast  or  uterine  cancers  is  not  large 
— the  majority  have  passed  the  curable  stage  before  the  diagnosis 
is  made.  This  has  been  and  will  be  true  of  the  stomach,  but  the 
results  should  be  much  better  than  they  are. 

The  curability  of  cancer  of  the  stomach  depends  upon — (1) 
The  histologic  structure  of  the  neoplasm;  (2)  its  location;  (3) 
extension  to  neighboring  structures;  (4)  lymphatic  infection;  (5) 
the  general  condition  of  the  patient.  It  is  essential  that  the  rela- 
tive value  of  the  manifestations  of  the  malignant  process  be  studied, 
for  upon  a  correct  appreciation  of  the  conditions  present  depends 
the  whole  question  of  treatment. 

1.  Every  cancer  is  at  one  time  a  local  process,  and  in  that  stage 
curable,  but  the  duration  of  this  stage  is  usually  short.  The  rapid- 
ity of  progress  of  carcinoma  of  the  stomach  is  largely  influenced  by 
the  relation  of  the  cells  to  the  stroma.  If  the  cellular  elements 
predominate,  the  growth  is  soft  and  its  extension  rapid.     If  the 


MALIGNANT    DISEASFIS    ()V    STO.M  VrH    AND    PYLORUS  !)  / 

stroma  is  in  excess  of  the  i)urencliyiua,  the  tumor  mass  is  harder 
and  slower  of  growth.  Ilemmeter  chissifies  the  mahgnant  ejji- 
theHal  tumors  of  the  stomach  into — (a)  Adenocarcinoma;  (h) 
cyhndric-cell  carcinoma;  (c)  mcdulUiry  carcinoma,  the  common 
degenerations  being  coUoid  and  scirrhus.  Tiie  colloid  type  is  an 
unfavorable  indication,  and  if  it  exists  to  any  extent,  indicates  a 
late  stage  of  the  disease  beyond  radical  intervention.  Secondary 
nodules,  the  result  of  a  primary  gastric  cancer,  are  especially  prone 
to  this  form  of  softening,  and  may  obscure  the  original  focus.  In 
the  metastatic  deposits  in  the  omentum  colloid  degeneration  may 
develop  a  tumor  of  very  large  size.  Bland-Sutton  describes  one 
weighing  10  pounds^  Scirrhus  refers  to  the  relatively  large  pro- 
portion of  connective-tissue  stroma  which  is  undergoing  more  or 
less  contraction,  and  indicates  a  slower  process.  This  variety  is  the 
most  common  form  of  gastric  carcinoma  (7'-2  per  cent.,  Brinton). 
Pyloric  growths  are  usually  scirrhus,  and  often  follow  the  lines 
of  the  blood-vessels  incircling  the  pyloric  end  of  the  stomach, 
producing  an  early  obstruction,  and  they  may  cause  death  while 
still  an  operable  growth.  In  some  cases  the  contraction  may 
not  take  place,  leaving  the  pylorus  open  and  gaping.  More 
rarely  diffuse  infiltrating  carcinoma  of  the  whole  stomach-wall 
may  exist,  either  as  a  primary  or  as  a  secondary  process.  This 
condition  is  more  common  than  cirrhosis  of  the  stomach  (Bristow's 
water-bottle  stomach),  and  often  mistaken  for  it.  Hektoen,  in 
describing  two  cases  of  the  primary  form,  calls  attention  to  the 
necessity  of  careful  search  for  the  carcinoma  cells  to  prevent  mis- 
conception as  to  the  nature  of  the  disease.  The  cylindric-cell 
carcinoma  is  the  most  favorable  form  of  disease  for  extirpation. 
It  is  slower  of  growth,  and  does  not  develop  adhesions  to  neighbor- 
ing organs  in  the  early  stages. 

2,  The  location  of  the  growth  is  important,  an  early  diag- 
nosis depending  to  some  extent  on  the  mechanical  features  present, 
and  the  accessibility  to  operative  procedures  is  very  largely  deter- 
mined by  the  situation.  Approximately,  10  per  cent,  involve  the 
cardiac  area,  30  per  cent,  the  body,  and  60  per  cent,  the  pyloric 
«nd  of  the  stomach  (Gussenbauer) .     The  cardiac  orifice  is  seldom 

VOL.  I — 7 


98  WILLIAM   J.    MAYO 

the  primary  seat  of  disease,  but  rather  an  extension  upward  from 
the  fundus  or  downward  from  the  esophagus.  The  symptoms  are 
painful  deglutition  and,  later,  obstructive  regurgitation.  The 
clinical  diagnosis  is  comparatively  easy,  but  the  situation  renders 
radical  operation  exceedingly  difficult  and  usually  impossible.  The 
progress  of  mahgnant  disease  of  the  cardia  is  rapid.  It  involves 
neighboring  structures  early,  and  death  follows  active  symptoms 
within  a  few  months.  Carcinoma  of  the  body  of  the  stomach  is 
most  difficult  of  early  diagnosis,  as  a  rule  presenting  few  symptoms 
until  it  is  well  advanced,  unless  by  extension  it  involves  one  of  the 
orifices  and  thereby  introduces  mechanical  phenomena.  Einhorn 
thinks  the  gastrodiaphanoscope  is  useful  in  outlining  a  tumor  of 
the  body.  The  ar-ray  has  been  used  for  the  same  purpose;  the 
utility  of  either  is  doubtful.  Kocher  says  that  under  deep  anes- 
thesia a  tumor  can  sometimes  be  mapped  out  early.  It  is  fortunate 
that  the  pylorus  is  the  part  so  often  affected.  The  mechanical 
obstruction  favors  an  early  diagnosis,  and,  as  shown  by  Winiwarter 
more  than  twenty  years  ago,  many  cases  die  from  starvation  pro- 
duced by  a  surgically  curable  growth.  Israel  states  that  the  pylorus 
itself  is  not  so  often  the  primarj^  seat  of  disease  as  has  been  believed. 
The  infiltration  from  any  place  in  the  pyloric  end  of  the  stomach 
naturally  extends  in  this  direction,  and  is  arrested  at  that  point.  In 
the  earlier  stages  the  process  cuts  off  rather  sharply  at  the  duodenum. 
The  situation  is  most  favorable  for  extirpation.  Obstruction  with 
resulting  dilatation  of  the  stomach  has  usually  been  the  most  im- 
portant factor  in  determining  operation  in  the  cases  submitted  to 
extirpation.  Kocher  states  that  if  food  is  regularly  found  in  the 
stomach  fourteen  hours  after  taking,  mechanical  obstruction  ex- 
ists. Myasthenia  with  retention  and  hyperesthetic  gastritis  with 
retention  produce  this  symptom,  and  are  not  necessarily  due  to  a 
mechanical  obstruction,  although  valve  formation  often  coexists. 
In  these  cases  chronic  dilatation  is  found,  and  often  hyperchlor- 
hydria  or  supersecretion.  While  the  differential  diagnosis  is 
not  difficult,  surgery  offers  the  best  means  of  cure  in  all  forms  of 
chronic  dilatation  of  the  stomach.  The  finding  of  a  dilated 
stomach  brings  the  case  within  surgical  limits,   and  if  chronic 


MALK.'NANT    DISEASES    OF    STOMAfU    AM)    I'^I.OUI  S  f)9 

rclciilioti  cxisls,  oilier  lliiiij^rs  Ix'iii;^  ('(luul,  ()pcriili\(;  rclit'f  is  in- 
dicated. Tlie  amoiiiil  of  dilatation  due  to  i)yIoric  cancor  depends 
to  some  extent  upon  tlic  situation  of  I  lie  pylorus.  If  held  high  by 
a  short  gastroliei)atic  oiucntuin,  the  stomach  is  emptied  by  musen- 
lar  eontraetion.  In  malignant  disease  compensutory  liypertrophy 
is  deficient,  and  dilatation  eomes  on  rapidly.  If  the  pylorus  lies 
low  down,  gravity  aids  the  onward  course  of  the  ingesta,  and  a 
larger  amount  of  obstruction  is  well  borne. 

3.  Direct  extension  to  surrounding  structures  is  through  ad- 
hesions; along  these  bands  the  malignant  infiltration  takes  place. 
In  most  instances  this  is  a  late  phenomenon,  and  acts  as  a  contra- 
indication to  ojjcration,  but  not  necessarily  so  if  the  ca.se  is  other- 
wise favorable.  The  adhesions  may  be  recent  and  due  to  a  septic 
process  rather  than  the  malignant  disease.  Advance  adhesive 
inflammation  takes  place  in  the  vicinity  of  ulceration,  and  later 
fistulas  may  form  between  the  stomach  and  duodenum  or  colon, 
or,  rarely,  with  the  abdominal  coverings.  Perforation  occurs  in 
about  6  per  cent,  of  the  cases,  causing  death  at  once  if  in  the  free 
peritoneal  cavity  or  subphrenic  abscess  if  protective  adhesions  exist. 
Indirect  extension  through  the  blood-vessels  is  rarely  the  cause 
of  metastatic  deposits.  The  arteries  are  very  resistant,  Init  the 
veins  are  more  easily  invaded,  and  from  the  infected  thrombus 
emboli  are  carried  to  the  liver,  lungs,  etc.  Peritoneal  inoculation 
is  a  rare  sequel  of  cancer  of  the  stomach.  The  most  common 
method  of  advance  is  by  extension  to  adjacent  structures,  and  thi.s. 
is  true  of  recurrences  after  extirpation,  which  are  usually  local. 
Prom  an  operative  standpoint  adhesions  are  a  serious  complica- 
tion, and,  as  they  are  usually  infiltrated  with  carcinomatous  cells, 
the  extirpation  under  such  circumstances  will  be  unpromising. 
Haberkant's  statistics  of  extirpation  show  that  where  adhesions 
were  extensive  72  per  cent,  of  the  patients  died.  If  no  adhesions 
existed,  only  27  per  cent.  died.  Gussenbauer  and  Winiwarter, 
in  542  cases  of  cancer  of  the  pylorus,  found  that  in  37  per  cent, 
there  were  no  adhesions;  in  -41  per  cent,  there  was  no  metastasis 
to  other  organs. 

4.  Lymphatic  infection  is  a  still   more  serious  complication. 


100  WILLL\M   J.    MAYO 

because,  if  palpable,  glandular  malignancy  can  be  established  and 
it  is  altogether  probable  that  the  involvement  has  passed  beyond 
reach.  Enlargement  of  glands  without  microscopic  proof  cannot 
be  considered  necessarily  malignant.  In  more  than  half  of  the 
29  cases  of  non-malignant  disease  of  the  stomach  which  I  have 
operated  upon  for  the  relief  of  dilatation  from  benign  causes  en- 
larged glands  could  be  palpated.  Fenger,  in  his  study  of  the  effects 
of  stone  in  the  common  duct  of  the  liver,  noted  the  fact  that  en- 
larged glands  could  sometimes  be  felt  about  the  head  of  the  pan- 
creas, leading  to  the  belief  that  malignant  disease  existed.  Halsted 
found  such  non-malignant  glandular  enlargement  occasionally  in 
malignant  disease  of  the  breast.  It  has  been  frequently  noted  in 
the  submaxillary  glands  during  the  course  of  lip  carcinoma,  and 
in  malignant  disease  accompanied  by  inflammatory  lesion.  In  due 
time  these  glands  undoubtedly  become  malignant,  just  as  inflam- 
matory adhesions  are  later  infiltrated.  In  my  experience  the  septic 
glands  are  smaller  and  softer  than  the  carcinomatous.  jNIikulicz 
says  the  lymphatic  glands  tributary  to  the  stomach  lie  in  four 
groups:  (a)  Along  the  lesser  curvature  and  cardia;  (b)  along  the 
greater  curvature;  (c)  in  the  gastrocolic  omentum;  {d)  about  the 
head  of  the  pancreas.  The  modern  operation  for  the  removal  of 
the  glands  -^ath  carcinoma  of  the  breast  suggests  a  similar  gland- 
ular extirpation  in  radical  operation  on  the  stomach.  Lindner  does 
not  believe  this  feasible.  In  28  recurrences  after  extirpation  15  were 
local,  12  distant,  and  only  1  involved  the  glands.  Bland-Sutton 
says  that  glandular  involvements  are  only  found  in  about  one- 
half  of  the  patients  dying  with  gastric  cancer.  It  is  probable 
that  this  is  too  low  an  estimate,  and  that  at  least  65  per  cent, 
dying  of  cancer  of  the  stomach  have  well-marked  glandular  in- 
volvement. In  the  earlier  stages,  however,  the  percentage  is 
smaller.  The  usual  route  of  travel  is  to  the  deep  glands,  liver,  etc. 
Binnie,  in  discussing  carcinoma  of  the  umbilicus  secondary  to 
cancer  of  the  stomach,  says  that  such  unusual  routes  of  travel 
are  indications  of  inflammatory  or  mechanical  impediments  in 
the  normal  channels.  He  believes  the  infrequent  recurrence  in 
the  glands  after  extirpation  of  gastric  cancer  is  due  to  the  destruc- 


MALKJXAXT    DISEASES   OF   STOMACH    AND    PYLORUS  10] 

tion  of  the  normal  lymphatics  at  the  time  of  operation.  Russell 
has  recently  pointed  out  that  the  cure  of  cancer  of  the  uterus  de- 
pends rather  upon  wider  local  extirpation  than  upon  removal  of 
the  glands,  and  this  statement  is  equally  true  of  the  stomach.  An 
investigation  leads  to  the  belief  that  glandular  infection  in  cancer 
of  the  stomach  is  not  uniform;  many  cases  die  without  such  in- 
fection, and  a  moderate  enlargement  may  be  septic.  Should  they 
become  infected,  their  situation  renders  radical  removal  practically 
impossible. 

5.  The  condition  of  the  patient  is  a  factor  of  importance.  Ma- 
lignant disease  of  the  stomach  has  a  peculiar  depressing  effect. 
The  nutrition  is  bad,  and  the  healing  power  is  greatly  impaired. 
Under  equal  conditions  a  most  formidable  operation  for  malig- 
nant disease  about  the  head  or  neck  would  be  well  borne.  A 
degree  of  cachexia  out  of  proportion  to  the  demonstrable  disease 
is  of  bad  omen,  unless  the  debility  can  be  shown  to  be  due  to  a 
mechanical  condition,  such  as  obstruction.  Ascites,  even  in  a 
limited  degree,  contraindicates  a  plastic  operation,  such  as  gastro- 
enterostomy, and  renders  any  kind  of  an  operative  procedure 
hazardous,  as  firm  adhesion  does  not  take  place.  Sarcoma  of  the 
stomach  is  a  rare  disease.  In  1899  Van  Valzah  and  Nisbet  found 
43  cases  recorded.  It  is  most  common  in  males  under  thirty-five 
years  of  age.  Finlayson  recently  reported  a  case  in  a  child  three 
years  of  age.  The  disease  may  present  itself  as  a  smooth,  rounded 
tumor,  and  by  its  weight  may  cause  considerable  prolapse  of  the 
stomach.  In  some  of  the  cases  reported  the  tumor  had  a  limited 
origin  in  the  stomach-wall  and  was  easily  extirpated.  It  rarely 
occurs  as  a  diffuse  sarcomatous  infiltration.  Sarcoma  seldom  con- 
tracts, and  involvement  of  the  orifices  does  not  produce  the  me- 
chanical interference  with  the  progress  of  the  food  which  is 
so  marked  a  symptom  of  scirrhus.  Incontinence  is  the  rule. 
Sarcoma  is  more  often  a  secondary  involvement  of  the  stomach 
than  is  carcinoma.  The  diagnosis  was  seldom  made  in  the  cases 
operated  upon,  the  operation  being  commenced  usually  under  a 
misapprehension  as  to  the  nature  of  the  growth.  In  the  majority 
of  instances  there  were  no  marked  gastric  symptoms  to  suggest 


102  WILLIAM   J.    MAYO 

that  the  abdominal  tumor  had  its  origin  in  the  stomach.  In  a 
few  cases  ulceration  and  hemorrhage  have  been  late  symptoms. 
In  1893  Baldy  removed  almost  the  whole  of  the  stomach  for  sar- 
coma without  success.  A  number  of  partial  gastrectomies  have 
been  recorded,  with  successful  outcome.  In  several  of  the  cases 
the  tumors  removed  were  of  considerable  size. 

The  exploratory  incision  for  suspected  cancer  of  the  stomach, 
instead  of  being  a  last  resort,  should  be  one  of  the  first,  and 
promptly  undertaken  if  the  condition  cannot  be  proved  to  be  non- 
malignant. 

A  median  incision  between  the  ensiform  cartilage  and  the  umbili- 
cus is  most  useful  for  exploration  upon  the  stomach.  A  small  open- 
ing readily  exposes  the  pyloric  portion,  which  is  the  most  common 
seat  of  disease.  The  writer  at  times  has  experienced  considerable 
difficulty  after  opening  the  abdomen  in  ascertaining  the  real  con- 
dition. 

What  are  the  local  appearances  which  enable  us,  by  palpation 
and  inspection,  to  say  that  a  certain  thickening  of  the  stomach- 
wall  is  malignant?  There  are  no  definite  signs  which  occur  in 
all  cases,  and  much  depends  upon  the  experience  of  the  surgeon. 
It  is  hardly  practicable  to  remove  a  portion  of  the  growth  and 
have  a  microscopic  examination  made  before  finishing  the  opera- 
tion, nor  is  such  practice  devoid  of  danger  of  inoculation.  In  all 
the  cases  I  have  explored  the  growth  was  hard  and  had  an  appear- 
ance of  increased  vascularity,  and  the  general  "feel"  of  the  dis- 
eased part  was  distinctly  malignant.  At  times,  with  the  involved 
area  thoroughly  exposed,  and  in  some  cases  laid  open  by  incision, 
it  is  impossible  to  state  from  macroscopic  examination  whether  it 
is  benign  or  malignant. 

Czerny's  experience  is  very  interesting.  Four  patients  in  which 
gastro-enterostomy  was  done  for  supposed  malignancy  lived  so 
long  as  to  preclude  the  possibility  of  cancerous  disease. 

Exploration  of  the  neighborhood  of  the  cardiac  orifice  is  dif- 
ficult and  often  unsatisfactor3\  A  small  opening  may  be  made 
into  the  stomach  cavity,  and  with  a  finger  introduced  through 
the  incision  the  anterior  wall  can  be  invaginated  to  enable  the 


MALI(;.\A.NT    DISKASKS    OI'    STOMATH    AM)    l'Vr,OIU  S  1  ().'{ 

exploring  digit  lo  sciirch  the  opening  int(j  tlie  esophagus.  Shouhl 
the  orifice  he  tightly  closed,  pressure  for  a  little  time  may  he  neces- 
sary before  a  dimi)lc  can  he  fell  at  I  he  normal  opening  (Abbe). 
For  inslrumcnlal  examination  of  the  <-anliac  orifice  a  small  in- 
cision should  be  made  in  the  anterior  wall  and  the  lesser  cur\ature 
held  taut;  this  forms  a  sulcus  leading  directly  to  the  opening 
(Richardson). 

The  body  of  the  stomach  anteriorly  can  be  readily  examined; 
by  traction  a  considerable  portion  can  be  drawn  forth  for  in- 
spection. Hy  an  incision  through  the  gastrocolic  omentum  the 
posterior  wall  can  also  be  inspected.  The  pylorus  is,  fortunately, 
easily  explored,  and  unless  adhesions  have  formed,  it  can  l)e 
brought  fully  out  of  the  abdominal  cavity.  If  it  i.s  held  within 
the  cavity  of  the  abdomen  and  under  the  li\  er  by  a  short  gastro- 
hepalic  omentum,  this  latter  structure  can  be  i)artly  divided  v.ith- 
out  injury  to  the  nerve-  or  blood-supply,  readily  mobilizing  the 
pylorus  and  upper  portion  of  the  duodenum.  The  writer  has  in 
five  instances  been  unable  to  make  an  exact  diagnosis,  even  after 
exploratory  incision.  In  two  cases  the  pylorus  was  held  high  up 
and  under  the  liver  by  adhesions,  the  symptoms  being  obstructive. 
If  the  disease  is  cancerous,  the  position  and  the  extension  to 
surrounding  structures  by  adhesions  would  prevent  radical  opera- 
tion. In  each  a  gastro-enterostomy  was  performed  for  relief  of 
the  mechanical  condition  present.  In  one  a  hard  mass  on  the 
posterior  wall  could  be  felt,  with  signs  of  extensive  inflammation 
in  the  lesser  cavity  of  the  peritoneum.  There  had  evidently  been 
a  perforation  at  one  time,  but  even  with  an  incision  in  the  anterior 
wall  of  the  stomach  I  was  unable  to  tell  whether  or  not  it  was 
malignant.  Here,  again,  gastro-enterostomy  was  performed  on 
the  supposition  that,  if  the  perforation  was  due  to  simple  ulcer, 
recovery  would  be  hastened,  and  if  carcinomatous,  some  relief 
would  be  experienced.  In  the  fourtli  case  a  small  stomach  was 
found  deep  under  the  liver;  with  a  finger  inside  the  stomach  cavity 
I  could  not  reach  the  cardiac  orifice.  The  clinical  evidence  led 
to  the  belief  that  the  obstruction  was  malignant,  and  gastrostomy 
was  decided  upon  without  further  attempt  at  diagnosis.     In  the 


104  WILLIAM   J.    MAYO 

fifth  case  the  evidences  of  malignant  obstruction  at  the  cardiac 
opening  were  marked;  the  condition  of  the  patient  was  such  that 
gastrostomy  was  done  as  quickly  as  possible  without  any  attempt 
to  explore  freely  as  to  the  nature  of  the  obstructive  lesion.  In  12 
cases  malignant  disease  was  quickly  shown  to  be  too  far  advanced 
to  extirpate,  and  not  presenting  symptoms  such  as  obstruction, 
requiring  palliation,  nothing  was  left  to  do  further  than  to  close 
the  abdominal  incision  rapidly.  In  one  of  my  earlier  explorations, 
in  which  extensive  malignant  disease  was  found  without  symptoms 
requiring  palliation,  the  incision  was  closed  and  the  patient  put  to 
bed  to  wait  the  usual  length  of  time  for  healing  to  take  place,  the 
debility  increased,  and,  while  he  lived  several  weeks,  he  was  unable 
to  return  to  his  home  before  death.  Since  that  time  I  have  closed 
the  incision  under  such  circumstances  with  permanent  silver-wire 
sutures  after  the  Halsted  plan.  The  patients  get  up  on  the  third 
day  and  leave  the  hospital  in  a  week. 

Silver  wire  buried  in  fixed  aponeurotic  structures,  in  my  ex- 
perience, does  not  give  rise  to  the  atrophy  necrosis  sometimes 
seen  when  placed  in  the  muscles.  The  hernia  liability  in  any 
event  is  of  no  great  consequence  to  the  victim  of  an  incurable 
malady.  It  may  be  justly  said  that  exploration  in  cases  of  ad- 
vanced malignant  disease  of  this  description  is  not  good  practice, 
yet  there  will  always  be  a  certain  number  of  cases  in  which  the 
diagnosis  will  be  uncertain,  although  advanced  disease  exists. 
The  extent  to  which  the  exploration  will  be  carried  will  vary  with 
different  operators.  Personally,  I  have  not  made  undue  effort 
to  perfect  the  diagnosis  if  extirpation  did  not  seem  proper,  and 
have  been  content  to  give  such  relief  as  the  circumstances  would 
permit. 

Complete  removal  of  the  stomach  has  won  a  foothold,  but 
to  what  extent  only  the  future  can  determine.  The  more  radical 
observers  believe  that  even  if  the  disease  has  affected  only  a 
limited  and  apparently  excisable  portion  of  the  stomach,  the 
whole  organ  should  be  removed,  that  pylorectomy  and  partial 
gastrectomy  are  not  based  on  correct  principles,  and  the  large 
percentage  of  local  recurrences  after  partial  operations  certainly 


MALKJNANT    DISIOASKS    OF    STOMACH    AM)    I'VI.OKI  S  ]()."> 

give  color  lo  this  view.  Bernays  calls  at  lent  ion  lo  llic  iinjirove- 
ment  in  llic  resiills  of  cancer  of  llic  ulcrns  since  complete  hys- 
tereeloniy  has  replaced  anipulalion  of  the  cervix,  and  helieves  tliat 
this  will  be  true  of  the  stomach.  On  the  other  hand,  the  number 
of  successful  complete  gastrectomies  are  so  few  and  of  such  short 
duration  that  the  problem  cannot  be  solved  at  this  time.  It  is, 
however,  altogether  {)robable  that  complete  gastrectomy  is  des- 
tined to  become  a  most  valuable  operation.  In  cancer  of  the  body 
of  the  stomach  nothing  else  in  the  way  of  radical  operation  offers 
a  reasonable  prospect  of  cure,  and  all  the  forms  of  pyloric  cancer 
with  a  tendency  to  infiltrate  the  body  of  the  stomach  can  be  placed 
in  the  same  category,  reserving  pylorectomy  and  partial  gastrec- 
tomy for  the  not  uncommon  cases  of  ring-like  infiltration.  These 
conditions  kill  by  obstruction,  and  there  can  be  no  more  reason 
for  a  complete  gastrectomy  in  such  cases  than  in  removal  of  the 
whole  of  the  large  bowel  for  cancerous  stricture  of  the  colon.  It 
is  in  these  cases  that  the  partial  operation  has  achieved  its  triumph. 
The  first  complete  removal  of  the  stomach  was  performed  by 
Conner,  an  operation  condemned  at  the  time  by  reason  of  its 
unfortunate  termination.  It  was  Schlatter's  success — not  his 
originality — that  called  attention  to  the  possibilities  of  gastrectomy, 
and  the  cases  of  Richardson,  Brigham,  Macdonald,  and  others 
quickly  gave  the  operation  a  standing.  The  ease  with  which  the 
duodenum  has  been  approximated  to  the  esophagus  in  many  of  the 
reported  cases  is  surprising;  it  certainly  is  an  important  factor  in 
the  result.  The  duodenum,  on  account  of  its  diameter  and  func- 
tion, offers  the  best  prospect  of  replacing  the  stomach,  and  it  is 
yet  to  be  determined  whether  an  opening  between  the  esophagus 
and  jejunum  would  serve  equally  as  well.  Schlatter's  case  was  of 
this  description,  and  the  result  was,  functionally,  as  satisfactory  as 
esophagoduodenostomy.  In  the  determination  of  the  advisability 
of  gastrectomy  the  ability  to  approximate  the  duodenum  to  the 
esophagus  is  of  im[)ortance.  Richardson  calls  attention  to  the  fact 
that  a  permanent  duodenostomy  might  be  made  should  it  be  impos- 
sible to  make  a  satisfactory  anastomosis.  A  number  of  the  deaths 
after  partial  as  well  as  complete  gastrectomy  has  been  caused  by 


106  WILLIAM   J.    MAYO 

including  a  portion  of  the  mesocolon  in  the  ligatures  used  to  free  the 
greater  curvature  of  the  stomach,  with  resulting  gangrene  of  the 
transverse  colon.  If  the  gastrohepatic  omentum  is  tied  off  first, 
the  fingers  can  be  slipped  underneath  the  pylorus  and  act  as  a 
safe  guide  to  the  ligation  and  division  of  the  gastrocolic  omentum. 
As  to  the  form  of  union,  the  Murphy  button  and  the  simple 
suture  plan  have  both  been  used.  Opinion  is  divided  as  to  which 
is  of  the  greater  merit.  As  elsewhere  in  the  gastro-intestinal 
tract,  the  results  seem  to  be  about  the  same,  the  one  used  depend- 
ing more  on  the  individual  preference  of  the  operator  than  on  any 
specific  indication.  Mayo  Robson,  in  the  Hunterian  Lectures  for 
1900,  gives  statistics  showing  a  death-rate  of  50  per  cent.;  the 
cases  from  which  to  draw  conclusions  are  as  yet  too  few. 

Pylorectomy  and  Partial  Gastrectomy 
Operations  limited  to  the  pyloric  end  of  the  stomach  and  its 
immediate  \dcinity  have  been  largely  practised  for  malignant 
disease,  and  the  result,  taken  as  a  whole,  has  not  been  satisfactory 
A  few  cures  have  taken  place  in  exceptionally  favorable  cases, 
mainly  the  malignant  strictures  where  the  mechanical  effects  led 
to  an  early  diagnosis  and  operation.  Limited  extirpations,  to  be 
successful,  must  go  wide  of  the  disease  on  the  stomach  side.  This 
is  particularly  true  if  the  infiltration  extends  laterally  along  the 
stomach-wall,  and  less  so  if  the  line  of  invasion  follows  the  blood- 
vessels in  a  circular  manner.  The  difficulties  of  diagnosis  have 
rendered  late  operations  the  rule,  and  the  absolutely  unfavorable 
prognosis  has  encouraged  operations  in  many  cases  unfit  for  so 
serious  a  procedure. 

The  results,  both  immediate  and  remote,  have  been  correspond- 
ingly bad.  An  occasional  patient,  apparently  with  a  hopeless 
extent  of  disease,  gets  well  after  extirpation  and  stays  well;  this 
leads  the  surgeon  to  an  effort  in  similar  cases,  with  very  disap- 
pointing results. 

An  analysis  of  the  more  recent  cases  of  Kocher  and  Maydl 
shows  a  decreasing  immediate  mortality  and  a  more  encouraging 
percentage  of  permanent  cures,  depending  on  an  earlier  diagnosis 


.maij(;n"a.\t  diseases  of  stomach  and  pyi.oki  s  107 

and  a  l)cttcr  selection  of  cases.  Maydl  lost  only  IG  per  cent, 
of  patients,  and  in  i8  per  cent,  there  was  early  recurrence,  the  re- 
maining 50  per  cent,  being  still  alive  at  the  time  of  his  report. 
Mayo  Rohson  says  the  evidence  shows  that  operation  can  !)e  rea- 
sonably expected  to  cure  one  patient  in  three  or  four. 

The  Kocher  operation  for  pylorectomy  and  partial  gastrectomy 
has  been  adopted  by  surgeons  generally,  and,  while  modified  in 
some  particulars  by  various  surgeons,  can  still  be  considered  the 
best  plan  of  procedure.  It  avoids  the  fatal  suture  angle  of  the 
Billroth  method  by  completely  closing  the  stomach  end  and  form- 
ing an  independent  anastomosis  between  the  duodenum  and  the 
remaining  portion  of  the  stomach.  In  a  comparison  of  these  two 
methods  Guinard  shows  a  mortality  in  148  cases  by  the  Billroth 
method  amounting  to  38  per  cent.,  and  in  64  cases  by  the  Kocher 
method  only  16  per  cent. 

In  our  experience  the  following  plan  was  found  satisfactory: 
First,  tie  and  divide  the  necessary  amount  of  the  gastrohepatic 
omentum;  this  mobilizes  the  pylorus  and  lesser  curvature  and 
permits  easy  delivery.  The  fingers  are  now  passed  behind  the 
pylorus  from  above  into  the  lesser  cavity  of  the  peritoneum; 
this  renders  ligation  of  the  gastrocolic  omentum  free  from  the 
danger  of  injury  to  the  vessels  in  the  transverse  mesocolon.  The 
stomach  should  then  be  clamped  above  the  disease,  and  a  cir- 
cular cut  made  with  a  knife  completely  around  the  healthy 
stomach  to  the  mucous  coat;  the  peritoneal  and  muscular  coats 
are  stripped  back  a  half  inch  and  the  few  bleeding  vessels  are 
caught  with  forceps  and  tied;  the  mucous  coat  is  cut  inch  by  inch 
from  above  downward  and  sutured  at  once  with  a  continuous  cat- 
gut suture,  preventing  leakage.  After  complete  separation  the 
tumor  is  covered  and  turned  to  the  right  out  of  the  way.  The 
muscular  coat  is  then  sutured  with  a  continuous  catgut  suture; 
finally,  the  peritoneum  is  turned  in  by  a  good  silk  Gushing  stitch. 
The  stomach  is  now  sutured  to  the  pedicles  of  the  tied  omenta, 
anchoring  it  to  the  right,  furnishing  further  protection  against 
leakage,  and  also  preventing  undue  traction  on  the  duodenum, 
which,  after  safe  amputation  lieyond  the  disease,  is  fastened  to 


108  WILLIAM   J.    MAYO 

the  anterior  wall  of  the  stomach  by  a  Murphy  button.  The  opera- 
tion is,  with  some  slight  modification,  the  Kocher  method.  Kocher 
uses  the  posterior  anastomosis  with  suture.  Czerny  has  used 
both  the  anterior  and  the  posterior  method  with  suture  and  the 
button.  He  thinks  it  makes  little  difference  in  the  result.  Greig 
Smith  says  that  any  extirpation  requiring  over  one  hour  for  its 
performance  is  open  to  serious  objection. 

Czerny  speaks  favorably  of  Tuholske's  method  of  doing  the 
operation  in  two  stages  where  the  patient  is  much  debilitated — 
first  the  gastro-enterostomy,  to  be  followed  in  three  weeks  by 
pylorectomy.  He  has  practised  this  in  one  case;  the  interval 
enables  the  patient  to  recuperate.  Kiimmell  has  also  advocated 
this  in  starvation  cases.  Czerny  says  that  one  objection  can  be 
made  to  this  method — the  adhesions  following  the  gastro-enteros- 
tomy interfere  with  the  extirpation.  It  is  a  question  whether  the 
average  patient,  after  experiencing  the  relief  afforded  by  successful 
gastro-enterostomy,  would  submit  to  a  second  operation,  and 
especially  to  one  which  promises  so  little  as  to  permanent  cure. 
Kocher  has  made  the  extirpation  by  his  present  method  30  times, 
with  5  deaths.  Malthe,  in  the  Christiana  clinic,  had  only  1  death 
in  11  cases.  Kocher,  out  of  a  total  of  57  extirpations,  had  11  pa- 
tients alive,  and  only  5  of  these  alive  long  enough  to  be  called  cured. 
The  immediate  mortality  of  pylorectomy  varies  from  25  to  55  per 
cent.  In  properly  selected  cases  it  should  have  as  low  or  a  lower 
death-rate  than  gastro-enterostomy.  Pylorectomy  requires  that 
the  patient  be  in  good  condition,  and  the  growth  in  the  early  stage — 
gastro-enterostomy  for  malignant  disease  has  no  such  limitations. 
Levy  has  described  an  operation  for  the  resection  of  the  cardiac 
end  of  the  stomach,  but  I  am  unable  to  find  that  it  has  been  per- 
formed upon  the  living  subject.  Chlumsky  says  that  any  death 
within  thirty  days  should  be  classed  as  operative  mortality,  and 
I  believe  this  conclusion  a  just  one. 

The  palliative  operations  depend  on  the  situation  of  the  growth, 
and  are  based  on  mechanical  conditions.  Malignant  obstruction 
of  the  cardiac  orifice  demands  gastrostomy,  and  best  at  an  early 
date,  without  waiting  for  marked  starvation  symptoms. 


MMAi.SASr    IHSEASES    OF    STOM-VrH    ANIJ    I'VLORUS  10!) 

Relief  from  the  irritation  of  the  i)a.s.sing  food  markedly  delays 
the  progress  of  the  disease,  comparing  in  this  respect  with  colos- 
tomy for  the  relief  of  cancer  of  the  rectum.  The  original  ojx'ra- 
tions  were  undertaken  with  the  one  view  of  feeding  the  patient, 
the  Fenger  operation  being  the  type.  The  writer  did  his  first 
gastrostomy  after  this  plan,  and  the  distress  from  the  leakage  al- 
most equaled  the  benefit.  In  many  cases  the  irritation  from  the 
leakage  and  enlargement  of  the  fistula  from  ulceration  constituted 
so  distressing  an  after-result  that  efforts  were  made  to  obviate  this, 
and  attempts  to  form  a  muscular  sphincter  about  the  opening  were 
more  or  less  successfully  adopted. 

The  von  Hacker  operation,  using  the  left  rectus  muscle-fibers 
for  this  purpose,  is  the  best  of  the  kind.  But  not  until  Witzel 
published  his  method  of  lateral  folding  of  the  stomach-wall  about 
a  rubber  tube,  forming  an  oblique  channel  and  valvular  opening, 
was  the  problem  solved.  We  have  made  four  gastrostomies  by  this 
method,  and  the  result  in  each  instance  was  most  gratifying.  The 
Kader  operation,  which  Curtis  says  was  first  described  by  Stamm, 
is  an  adaptation  of  the  \Yitzel  method,  the  only  difference  being 
that  the  tube  is  introduced  directly  into  the  cavity  of  the  stomach 
and  the  walls  brought  up  about  it  by  a  circular  purse-string  suture 
(Stamm)  or  by  lateral  interrupted  sutures  (Kader).  The  object  is 
to  cause  a  cone  or  nipple-like  projection  to  present  into  the  gastric 
cavity.  In  the  one  case  in  which  the  writer  used  this  method  the 
result  was  equally  as  good  as  in  the  Witzel  plan.  It  is  of  special 
advantage  in  some  cases  on  account  of  the  ease  with  which  a  gas- 
trostomy can  be  quickly  done  on  a  very  small  stomach. 

The  Marwedel  operation  is  also  a  modification  of  the  Witzel, 
the  rubber  tube  being  obliquely  buried  in  the  wall  of  the  stomach 
itself.  It  is  highly  commended  by  Dennis,  and  undoubtedly  is  as 
perfect  as  the  method  of  either  Witzel  or  Kader.  The  Ssabanajew- 
Frank  method  of  gastrostomy  is  on  an  entirely  different  principle, 
and  has  the  great  advantage  in  not  requiring  a  tube.  The  fistula 
formed  is  a  mucocutaneous  one,  and,  therefore,  permanent,  while 
by  the  peculiar  displacing  upward  of  the  cone  of  the  stomach 
brought  out  of  the  deeper  layers  of  the  abdominal  wall,  a  spout- 


110  WILLIAM   J.    MAYO 

like  opening  is  maintained  which  is  self-closing  and  does  not  leak. 
The  one  disadvantage  is  the  difficulty  of  making  the  operation  on  a 
contracted  stomach.  McCosh  gives  the  mortality  of  gastrostomy 
for  malignant  disease  at  30  per  cent.  The  palliative  treatment  of 
advanced  cancer  of  the  body  of  the  stomach  is  unsatisfactory;  for- 
tunately, mechanical  conditions  arising  from  this  form  of  disease 
are  infrequent.  Occasionally,  on  exploration  an  inoperable  growth 
of  this  kind  is  found,  and  the  question  is:  Can  we  prolong  life  or 
induce  future  comfort?  If  sufficient  healthy  stomach  remains  on 
the  cardiac  side  to  permit  gastro-enterostomy,  this  should  be  done. 
The  cureting  of  such  growths  through  a  gastrotomy  wound,  advo- 
cated by  Bernays,  has  little  to  commend  it,  nor  can  the  actual  cau- 
tery, so  useful  in  advanced  cancer  of  the  uterus,  be  used  to  any 
great  advantage.  Should  the  growth  involve  the  orifices  of  the 
stomach,  starvation  may  necessitate  duodenostomy  or  jejunostomy 
for  feeding  purposes.  Edward  Martin  reports  a  case  relieved  by 
duodenostomy,  made  in  a  manner  similar  to  the  gastrostomy  of 
Witzel. 

Jejunostomy  has  had  some  degree  of  prominence,  and  at  one 
time  was  a  rival  of  gastro-enterostomy.  Maydl  performed  2.5 
jejunostomies  with  4  deaths,  and  strongly  urges  the  operation  in 
selected  cases.  Heidenhain  reports  several  very  satisfactory  re- 
sults from  this  operation,  and  believes  that  in  cases  in  which  the 
gastro-intestinal  fistula  must  be  made  at  a  point  within  the  possible 
future  progress  of  the  disease,  jejunostomy  is  indicated  rather  than 
gastro-enterostomy . 

Obstructions  at  the  pyloric  opening  are  most  common,  and  the 
gastric  retention  Avhich  results  demands  relief.  Gastro-enteros- 
tomy is  the  most  generally  useful  operation  performed  on  the 
stomach,  in  suitable  cases  prolonging  life,  relieving  pain,  and  pro- 
moting comfort. 

It  would  be  an  unprofitable  undertaking  to  go  into  the  various 
methods  of  making  the  anastomosis,  as  the  literature  of  the  sub- 
ject is  already  enormous.  Two  methods  of  making  gastro-enter- 
ostomy have  stood  the  test  of  time — the  simple  suture  operation 
and  the  Murphy  button.     At  the  present  stage  of  development 


MALKINANT    DISKASKS    OK    STOMACH    AM)    I'VLOItIS  111 

the  results  are  about  llie  sarue,  dcpcnditi^  more  on  the  exjXTiciK-e 
of  the  operator  than  on  the  method  employed.  In  performing 
the  <)[)eration  hy  either  method  it  is  important  that  the  jejunum 
should  l)e  grasped  at  its  origin  and  a  eoil  from  14  to  Hi  inehes  in 
length  formed.  At  this  point  the  mesentery  is  of  sufficient  length 
to  prevent  traction.  Care  should  be  taken  to  have  the  direction 
of  the  peristalsis  the  same  in  the  stomach  and  intestine  when  the 
anastomosis  is  effected.  There  has  been  considerable  discussion 
as  to  whether  the  fistula  should  be  established  on  the  anterior 
(Woifler)  or  posterior  wall  (von  Hacker)  of  the  stomach.  The 
latter  necessitates  an  artificial  opening  into  the  lesser  cavity  of  the 
peritoneum,  to  reach  the  desired  part  of  the  posterior  wall,  and 
requires  a  larger  incision  with  greater  exposure.  Its  supposed  ad- 
vantages are:  that  gravity  will  aid  in  passing  the  food  downward, 
and  if  the  button  has  been  used,  that  it  is  less  liable  to  be  retained 
in  the  stomach;  and,  lastly,  that  regurgitant  vomiting  of  bile  and 
pancreatic  juices  is  less  frequent — all  of  which  are  important  points 
in  favor  of  this  locality'  for  anastomosis.  Carle  and  Fantino  dem- 
onstrated the  superior  advantages  of  the  posterior  operation. 
These  investigators  also  showed,  by  experimental  work,  that  bile 
was  frequently,  if  not  usually,  present  in  the  stomach  for  three 
months  after  gastro-enterostomy,  and  in  moderate  quantities  did 
not  interfere  with  digestion.  On  the  contrary,  at  the  Breslau 
clinic  the  anterior  method  gave  the  best  results.  If  the  posterior 
operation  is  chosen,  the  suggestion  of  Meyer,  that  the  edges  of  the 
divided  mesocolon  be  sutured  to  the  posterior  wall  of  the  stomach, 
should  be  carried  out  to  prevent  contraction  of  the  mesenteric 
opening.  For  the  anterior  operation,  a  point  on  the  healthy  por- 
tion of  the  stomach  should  be  chosen  as  near  the  pylorus  as  will 
probably  remain  free  from  encroachment  of  the  disease.  It  should 
be  placed  near  the  greater  curvature.  We  endeavor  to  get  the 
lower  border  of  the  anastomotic  opening  about  one  inch  above  the 
inferior  border  of  the  stomach.  When  completed,  the  traction 
weight  of  the  attached  bowel  draws  the  stomach  over  until,  at  the 
point  of  attachment,  the  anterior  wall  becomes  the  inferior,  and 
a  funnel-shaped  entrance  into  the  bowel  is  secured.     This  can  b;» 


112  WILLIAM   J.    MAYO 

readily  observed  before  closing  by  lifting  up  the  abdominal  wall 
with  a  retractor,  exposing  the  field  of  operation.  I  believe  that 
this  mechanical  condition  in  the  completed  gastro-enterostomy 
prevents,  to  a  large  extent,  the  vicious  circle  of  the  biliary  and 
pancreatic  juices,  which  has  proved  so  prolific  a  source  of  danger 
to  the  patient. 

The  anterior  operation  has  usually  been  made  too  high  up  on 
the  stomach-wall.  The  anastomosis  should  be  at  a  low  point, 
so  that  gravity  will  empty  the  stomach  and  prevent  the  entrance 
of  bile.  Of  11  anterior  gastro-enterostomies  which  I  have  made 
for  malignant  disease,  in  only  2  cases  was  regurgitant  vomiting 
marked.  One  subsided  after  a  lavage,  and  the  second  required 
lavage  once  or  twice  a  day  for  five  days;  both  cases  recovered. 
Of  20  gastro-enterostomies  made  for  non-malignant  disease,  in 
one  was  regurgitant  vomiting  present.  It  is  a  more  common  com- 
plication of  malignant  disease,  and  perhaps  in  part  due  to  the 
changed  nutrition  affecting  the  glandular  secretions  as  well  as  the 
reduction  in  the  motor  power  so  characteristic  of  cancer  of  the 
stomach. 

Entero-anastomosis  between  the  proximal  and  distal  limbs  of 
the  jejunum,  as  advocated  by  Jaboulay-Braun,  to  prevent  this 
complication,  has  been  considered  of  value  by  Weir.  The  latter 
uses  a  small  Murphy  button  for  the  purpose,  and  with  long  forceps 
introduces  each  half  of  the  button .  from  inside  the  lumen  of  the 
intestine,  making  a  small  opening  through  the  intestinal  wall 
large  enough  to  admit  the  cylinders  and  clamps  without  sutures. 
Mikulicz  made  entero-anastomosis  four  times  after  regurgitant 
vomiting  had  commenced,  as  a  secondary  operation,  with  success 
in  checking  regurgitation.  Doyen  has  recommended  that  the 
bowel  be  divided  and  the  distal  end  anastomosed  to  the  stomach, 
the  proximal  end  being  joined  to  the  small  bowel  below,  in  this  way 
avoiding,  as  be  believes,  the  danger  of  the  vicious  circle,  and  pre- 
venting dilatation  of  the  proximal  portion  of  the  loop. 

Rutkowski  adds  to  the  gastro-enterostomy  a  Witzel  or  Kader 
gastrostomy,  and  introduces  a  rubber  tube  from  the  surface 
through  the  external  fistula  and  the  stomach  into  the  intestine 


MALIGNANT    DISEASES    OF    STOMACH    AM)    I'VLORUS  113 

hy  way  oi  the  anastomotic  opening;.  \\'it/,el  speaks  highly  of 
this  method,  both  in  i)reventing  the  establishment  of  a  false  route 
and  also  as  j)rovi(ling  a  means  of  early  feeding  through  the  tube. 
It  has  been  recommended  that  the  tube  be  fastened  into  the  gastro- 
enterostomy opening  by  an  absorbable  suture,  to  prevent  it  from 
slipping  upward  into  the  stomach.  The  necessity  for  such  com- 
plicated operations  for  the  ])urj)ose  of  preventing  regurgitant  vom- 
iting is  oj)en  to  serious  question.  Czerny  had  only  1  fatal  case  of 
intestinal  regurgitation  in  65  gastro-enterostomies,  and  this  case 
was  complicated  by  free  hemorrhage  from  an  ulcerating  carci- 
noma. Czerny  believes  the  button  prevents  spur  formation  while 
in  place,  and  prefers  the  posterior  operation.  Mikulicz  had  74 
gastro-enterostomies  in  the  Breslau  clinic,  with  24  deaths,  spur 
formation  accounting  for  6,  or  25  per  cent,  of  the  mortality.  In 
the  fatal  cases  due  to  spur  formation  the  proximal  loop  was  enor- 
mously distended  and  the  intestinal  tract  empty,  the  patients  dy- 
ing of  starvation.  Mikulicz  abandoned  the  posterior  operation  on 
this  account.  At  the  time  of  the  report  he  was  using  the  anterior 
method  with  the  ^Murphy  button,  and  his  results  were  very  satis- 
factory. The  suture  operation  of  Wolfler  brings  the  lateral  wall 
of  the  jejunum  to  the  side  of  the  stomach,  and  Senn  fixes  the  bowel 
at  several  points  each  side  of  the  opening  to  prevent  angulation, 
and  favors  a  long  visceral  incision  to  prevent  contraction.  Kocher 
loops  the  bowel  up  in  such  a  manner  as  to  produce  a  rather  marked 
angle,  the  anastomosis  being  at  the  apex  of  the  knuckle.  Fenger 
has  modified  the  anterior  suture  operation  of  Kocher  in  a  most 
important  particular,  and  theoretically  it  would  appear  to  be  a 
good  method.  The  suturing  is  proceeded  with  as  in  the  Kocher 
l)lan,  but  from  the  middle  of  each  half  of  the  anterior  surface  of 
the  stomach  and  bowel  an  incision  from  three-quarters  of  an  inch 
to  an  inch  in  length  is  made — that  is,  from  the  center  of  the  un- 
finished upper  half  toward  the  lesser  curvature  ol  the  stomach  and 
downward  along  the  convexity  of  the  bowel  to  the  same  extent. 
On  closing  this  wound  the  anterior  portion  of  the  anastomotic 
opening  is  greatly  lengthened,  and  spur  formation,  with  its  at- 
tendant evils,   prevented.     It  is  not  so   injuriously  affected   liy 

VOL.  I — 8 


114  WILLIAM   J.    MAYO 

future  contraction  as  the  Kocher  operation.  Fenger's  modifica- 
tion is  simply  "pyloroplasty"  upon  the  anterior  surface  of  the 
opening. 

The  writer  has  used  the  Murphy  button  in  all  his  operations, 
and  has  been  satisfied  with  the  results.  Death  followed  3  out  of 
11  gastro-enterostomies  for  malignant  disease,  and  in  only  1  out 
of  20  non-malignant  cases.  In  no  case  was  the  button  found  to 
be  at  fault.  Two  died  of  pneumonia  from  aspiration  and  2  of 
exhaustion. 

A  form  of  collapse  after  operation  for  malignant  disease  in  the 
abdomen,  coming  on  about  the  fourth  day  in  my  experience,  has 
been  a  rather  common  fatal  termination.  The  postmortem  does 
not  show  adequate  cause  for  the  exhaustion.  In  the  Breslau 
clinic  collapse  was  given  as  the  cause  of  death  in  13  out  of  24  fatal 
cases.  In  using  the  button  the  female  half  should  be  placed  in 
the  intestine  first  after  a  preliminary  purse-string  suture.  The 
stomach-wall  should  be  cut  to  the  mucous  coat  before  placing  the 
suture,  and  the  latter  should  be  close  to  the  margins  of  the  incision, 
to  render  approximation  easy;  otherwise  the  thick  wall  of  the 
stomach  will  rufSe  up  and  expose  the  suture  at  some  point.  This 
is  less  true  of  malignant  disease  than  of  non-malignant,  as  the 
shorter  period  of  obstruction  does  not  permit  of  adequate  com- 
pensation, and  the  ability  to  develop  muscular  structure  is  defi- 
cient. 

Klimmell  places  the  stomach  half  of  the  button  in  position  and 
closes  the  incision  to  the  cylinder  by  sutures.  In  a  later  report 
Kummell  says  that  he  has  since  had  an  accident  from  this  cause, 
and  he  has  now  returned  to  the  purse-string  suture  of  Murphy. 
Kammerer  speaks  of  the  button  as  being  especially  adapted  for 
the  posterior  operation  and  the  suture  for  the  anterior.  Supple- 
mentary sutures  outside  of  the  button  are  unnecessary,  and  may 
prove  a  source  of  danger.  I  have  never  used  them.  In  using  the 
button,  one  should  be  careful  to  prevent  a  hematoma  infiltrating 
the  walls  of  the  stomach  outside  the  grasp  of  the  button,  as  the 
sloughing  process  may  cause  an  infection  of  the  clot  and  perfora- 
tion beyond  the  limiting  adhesions.     The  main  objection  made  to 


.malh;\.\nt  diseases  of  stoniac  ii  and  pylorus  11.> 

Ihe  l)ullon  is  that  it  often  falls  hack  into  the  stomach.  This 
occurred  in  a  iiurnhcr  of  my  cases,  and  no  harm  has  resulted. 

Weir  and  Kiiinmell  have  each  modified  the  intestinal  half  of 
the  button,  enlarging  it  in  such  a  way  as  to  prevent  its  passing 
into  the  stomach.     I  do  not  know  of  the  value  of  the  modification. 

Malthc  says  that  if  the  button  in  position  lies  to  the  right  of 
the  spinal  column,  it  will  pass  downward;  if  to  the  left,  it  will 
droj)  l)ack  into  the  stomach.  For  some  time  I  have  paid  no 
attention  to  the  passing  of  the  button.  Meyer  speaks  of  finding 
the  button  in  the  rectum  in  many  of  his  cases.  Colicky  pains  and 
symptoms  of  obstruction  may  appear  while  the  button  is  in  transit. 
This  readily  subsides  by  prohil)iting  food  for  a  short  time. 

Contraction  of  the  anastomotic  opening  after  the  button 
operation  does  not  often  occur.  Meyer  was  able  to  find  only  one 
case.  That  some  contraction  should  take  place  with  the  diminish- 
ing size  of  a  dilated  stomach  is  to  be  expected,  but  in  none  of  my 
cases  has  failure  to  empty  the  stomach  occurred  after  the  operation. 
I  have  one  case  of  over  six  years'  duration,  and  several  beyond 
three  years.  Gastro-enterostomy  for  malignant  disease  has  a  mor- 
tality of  about  38.3  (Robson).  Czerny,  in  65  recent  cases,  had 
a  mortality  of  38.5.  Mikulicz,  74  cases;  mortality,  3*2  per  cent. 
Pernian,  of  Stockholm,  4'2  cases  and  15  deaths. 

The  special  preparation  of  the  stomach  for  operation  is  of  im- 
portance. Under  normal  conditions  bacteria  do  not  flourish  in  the 
stomach,  although  present  under  ordinary  food  conditions.  With 
carcinoma,  motor  insufficiency,  retention,  and,  in  the  later  stages, 
ulceration,  present  conditions  favoring  development  of  germs,  as 
well  as  the  saprophytes  of  putrefaction.  In  Halsted's  clinic  Cush- 
ing  has  been  able  to  secure  a  high  degree  of  sterilization  of  the 
stomach  by  means  of  careful  antiseptic  cleansing  of  the  teeth  and 
mouth  and  heat  sterilization  of  the  food.  Lavage  as  a  means  of 
aifling  the  cleansing  process  is  very  necessary.  The  mechanical  re- 
moval of  the  gastric  contents  washes  out  the  unabsorbed  food- 
[)roducts  and  prevents  decomposition. 

Guillot  does  not  favor  lavage  immediately  prior  to  operation 
upon  the  stomach,  believing  that  it  tends  to  weaken  the  patient 


116  WILLIAM   J.    MAYO 

at  a  critical  time.  He  also  opposes  purgation  before  the  operation 
on  the  same  grounds.  Among  surgeons  generally  the  opposite 
view  is  held,  lavage  and  purgation  being  considered  essential  as 
preliminary  preparations. 

The  writer  does  not  ordinarily  favor  marked  changes  in  the 
diet  of  patients  shortly  before  operation.  The  patient  of  average 
intelligence  can  materially  aid  the  surgeon  in  selecting  articles 
of  diet  which  experience  has  taught  him  cause  the  least  harm. 
If  these  articles  can  be  sterilized  by  cooking  and  the  remains 
be  removed  by  gastric  lavage  before  decomposition  occurs, 
we  will  have  accomplished  something  in  the  way  of  securing 
a  proper  wound-site.  Undoubtedly  a  greater  amount  of  good 
would  be  accomplished  by  a  diet  beginning  some  days  before 
operation,  but  the  necessary  experimentation  to  secure  proper 
feeding  takes  valuable  time,  and  the  immediate  result  is  often 
temporarily  to  disarrange  the  already  enfeebled  digestive  f>ower. 
Attempts  to  add  to  the  patient's  strength  before  operation  by 
rectal  feeding  to  supplement  gastric  absorption  may  be  objection- 
able. In  many  cases  the  rectum  becomes  intolerant  after  a  few 
days,  and  its  value  may  in  this  way  be  seriously  impaired  for  car- 
rying on  nutrition  after  operation.  My  own  experience  has  been 
that  the  patient  does  fully  as  well  if  either  method  be  employed. 
Not  more  than  a  few  days  should  be  spent  in  preliminary  prepa- 
ration. The  stomach  should  be  carefully  emptied  of  its  contents 
just  previous  to  the  operation;  this  is  seldom  as  successful  as  one 
could  wish,  since  the  water  will  often  return  quite  clear,  and  on 
opening  the  stomach  a  few  minutes  later  a  quantity  of  dirty  fluid 
will  be  encountered.  This  renders  accidental  wound  soiling  pos- 
sible, and  in  elevating  the  stomach  out  of  the  abdominal  incision 
gravity  may  cause  the  fluids  to  pass  into  the  esophagus.  Pneu- 
monia under  such  circumstances  is  very  liable  to  occur  after 
operation.  I  had  two  deaths  from  this  cause.  Fifteen  out  of  a 
total  of  20  deaths  after  operations  on  the  stomach  in  the  Heidel- 
berg clinic  were  from  pneumonia.  Czerny  does  not  think  the 
pneumonia  due  to  the  anesthetic,  as  it  occurred  twice  in  five  opera- 
tions under  cocain,  and  as  it  often  came  on  in  the  first  forty-eight 


MALIGNANT    DISKASKS    OF    STOMACH    AND    I'VLOKIS  117 

hours,  it  could  not  be  clue  to  confinemont  to  bed.  In  his  cxix'ri- 
ence  the  complication  was  most  common  in  males  with  a  pre- 
vious bronchitis  or  emphysema,  and  due,  he  believes,  to  the 
incision  interfering^  with  abdominal  respiration.  In  de!)ilitated 
cases  very  little  anesthetic  is  needed — a  preliminary  hypoder- 
matic of  morphin,  with  just  enough  ether  or  chloroform  to 
enable  painless  division  of  the  abdominal  coverings  and  again 
to  close.  No  pain  is  felt  during  the  gastro-intestinal  manipu- 
lations. Local  anesthesia  by  cocain  in  very  debilitated  sub- 
jects is  an  ideal  method,  provided  the  operation  is  short  and 
does  not  reciuire  traction  on  the  margins  of  the  abdominal  incision. 
Abbe  and  others  have  used  it  to  a  considerable  extent  in  gastric 
surgery.  The  experience  of  Bloodgood  and  Gushing  in  hernia 
work,  and  Matas  in  cocainization  of  nerve-trunks,  suggests  a  wider 
field  for  its  employment.  The  after-care  is  mainly  to  counteract 
shock,  which  the  nearness  to  the  great  sympathetic  ganglion  and 
direct  injury  to  the  terminal  filaments  of  the  vagi  often  renders 
severe.  Morphin,  strychnin,  and  atropin  are  useful  to  meet  indi- 
cations, and,  if  necessary,  saline  infusions.  Rectal  enemata  of  hot 
saline  solution  or  coffee  are  valuable  adjuvants  to  prevent  col- 
lapse. After  the  immediate  danger  has  been  overcome,  every 
effort  to  prevent  exhaustion  and  death  at  a  later  stage  must  be- 
made.  The  majority  of  surgeons  prefer  rectal  feeding  for  the 
first  few  days.  Successful  rectal  feeding  requires  experience  and 
good  judgment;  the  tendency  is  to  overfeed  and  to  use  larger 
quantities  than  are  well  borne.  The  need  of  liquids  is  most  ap- 
parent, and  large  enemata  of  saline  solution  at  least  once  in  twenty- 
four  hours  meet  this  indication.  The  general  tendency  is  to  earlier 
feeding  by  mouth,  and  less  reliance  is  placed  on  rectal  alimenta- 
tion. Rectal  feeding  carries  the  patients  along,  but  it  is  inade- 
quate, and  they  do  not  gain. 

Guillot  begins  liquid  nourishment  by  mouth  two  hours  after 
partial  extirpation  of  the  stomach,  and  Roux  gives  whatever  the 
patient  desires  and  as  soon  as  called  for.  This  practice  shows 
great  coufidence  in  the  methods  of  suture  in  preventing  leakage, 
but  after  an  abdominal  operation  of  this  magnitude,  digestion  for 


118  WILLIAM   J.    IVIAYO 

the  first  twenty -four  hours  is  nearly  at  a  standstill,  and  food  under 
such  circumstances  is  liable  to  do  harm.  Chlumsky,  in  his  ex- 
periments as  to  the  strength  of  union  after  intestinal  anastomosis, 
demonstrated  that  from  the  third  to  the  fifth  day  the  union  was 
weakest.  There  was  little  difference  between  the  button  and 
suture  in  this  respect.  These  conclusions  are  borne  out  by  clinical 
experience,  and  care  should  be  exercised  in  feeding  until  union  is 
complete.  Elderly  people  bear  confinement  to  bed  badly,  and 
do  much  better  if  allowed  to  be  up  within  the  first  week. 


LYMPHATIC  INVOLVEMENT  IN  CANCER  OF 
THE  STOMACH* 

WILLIAM    J.    MAYO 


To  THE  Editor  of  the  "Medical  Record":  In  the  issue  of 
the  "IVFedical  Record,"  IVIay  5,  1900,  is  an  abstract  of  a  paper  on 
"Malignant  Diseases  of  the  Stomach  and  Pylorus,"  read  before 
the  American  Surgical  Association.  In  the  abstract  I  am  quoted 
as  saying  that — "Lymphatic  involvement,  so  called,  is  now  known 
to  be  a  simple  septic  glandular  enlargement,  the  relation  between 
the  abdominal  glands  and  the  carcinoma  being  utterly  different 
from  that  which  exists  between  the  breast  and  axilla;  and  that 
abdominal  adenitis  is,  therefore,  of  little  importance." 

What  I  did  say  is,  "Lymphatic  infection  is  a  still  more  serious 
comjilication,  because,  if  palpable,  glandular  malignancy  can  be 
established,  and  it  is  altogether  probable  that  the  involvement 
has  passed  beyond  reach."  In  28  cases  of  non-malignant  dila- 
tations of  the  stomach  from  various  causes  which  I  have  operated 
upon,  in  more  than  half  the  enlarged  glands  could  be  palpated, 
due  to  an  accompanying  chronic  gastritis.  This  may  be,  and 
frequently  is,  true  of  cancer  of  the  stomach,  the  enlarged  glands 
being  the  result  of  septic  complications.  The  modern  operation 
for  the  removal  of  the  glands  with  carcinoma  of  the  breast  sug- 
gests a  similar  glandular  extirpation  in  radical  operations  on  the 
stomach.  Lindner  does  not  believe  this  feasible.  In  28  recurrences 
after  extiri)ation  15  were  local,  12  distant,  and  only  1  involved 
the  glands.  An  investigation  leads  us  to  the  belief  that  glandular 
infection  in  cancer  of  the  stomach  is  not  uniform, — many  such 
patients  die  without  such  involvement, — and  that  a  moderate  en- 

*  Reprinted  from  the  "Med.  Record."  1900,  Ivii,  p.  OiS. 
119 


120  WILLIAM   J.    AL\TO 

largement  may  be  septic.     Should  they  become  infected,  their 
situation  renders  radical  removal  practically  impossible. 

Inasmuch  as  involvement  of  the  lymphatics  takes  place  in 
at  least  two-thirds  of  the  cases  of  cancer  of  the  stomach,  I  feel 
that  the  statement  should  be  corrected,  and  more  especially  in 
consideration  of  the  large  circulation  of  your  journal. 


SOME  OF  THE  DISEASES  COMMON  TO  THE 

STOMACH:   THEIR  SURGICAL 

TREATMENT* 

WILLIAM    J.    MAYO 


There  are  a  few  points  in  the  anatomy  of  the  stomach  which 
are  of  especial  importance  in  their  surgical  relations,  and,  as  the 
first  portion  of  the  duodenum  in  its  origin,  development,  and  func- 
tion partakes  more  of  the  stomach  than  the  intestine,  it  may  well 
be  considered  at  the  same  time.  This  part  of  the  duodenum  may 
be  said  to  be  the  vestibule  of  the  small  intestines,  for  it  is  not  until 
the  biliary  and  pancreatic  juices  are  poured  into  the  second  portion 
that  the  real  work  of  the  small  bowel  begins.  Up  to  this  point  the 
acid  reaction  and  character  of  its  contents  predispose  to  the  same 
forms  of  ulceration  and  kindred  phenomena  which  mark  the  stom- 
ach rather  than  the  small  bowel. 

One  mentally  grasps  the  anatomy  of  the  stomach  by  consider- 
ing it  an  intestine  with  a  double  mesentery,  the  upper  part  being 
formed  by  the  lesser  omentum  and  gastrophrenic  and  splenic 
ligaments.  This  is  the  most  fixed  part  of  the  stomach-wall.  The 
lower  attachment  is  formed  by  the  gastrocolic  portion  of  the 
great  omentum,  which  gives  mobility  to  the  organ.  The  anterior 
and  posterior  surfaces  are  covered  by  peritoneum.  The  blood- 
supply  is  from  three  principal  sources,  and  in  its  freedom  of  anas- 
tomosis calls  to  mind  the  palmar  arch  or  the  circle  of  Willis.  This 
allows  of  extensive  incisions,  and  gives  a  certainty  of  wound  heal- 
ing which  is  lacking  in  the  small  intestine  with  its  single  mesentery. 
The  smaller  vessels  lie  beneath  the  mucous  coat,  and  the  thickness 

*Read  before  the  Minnesota  Academy  of  Medicine,  November  7,  1900.  Re- 
printed from  "The  St.  Paul  Medical  Journal,"  January,  1901. 

121 


122  WILLIAM   J.    MAYO 

and  looseness  of  attachment  of  this  latter  membrane  allow  its 
easy  separation,  permitting  independent  suture.  The  gastro- 
hepatic  portion  of  the  lesser  omentum  anchors  the  pylorus  behind 
the  ribs,  and  by  division  of  this  structure  the  distal  end  of  the 
stomach  can  be  easily  mobilized. 

The  position  of  the  normal  stomach  is  a  disputed  point. 
Luschka  maintains  that  the  direction  is  nearly  vertical,  the  lesser 
curvature  corresponding  with  the  median  line  of  the  body,  and 
there  is  no  doubt  but  that  this  is  the  normal  position  in  infants. 
The  weight  of  authority  gives  to  the  stomach  of  the  adult  a  small 
degree  of  obliquity.  The  cardiac  orifice  is  fixed  at  the  twelfth 
dorsal  vertebra,  and  the  pylorus  lies  behind  the  edge  of  the  right 
costal  border,  on  a  line  with  the  tip  of  the  ensiform  cartilage. 
Doyen  says  that  the  vertical  position  of  the  lesser  curvature  gives 
to  the  pyloric  antrum  and  first  portion  of  the  duodenum  the  ap- 
pearance of  a  fish-hook. 

When  the  stomach  is  distended,  it  rotates  somewhat  on  its 
long  axis,  the  pylorus  passing  downward  and  to  the  right.  With- 
out going  into  the  question  of  the  exact  position  of  the  normal 
stomach,  it  seems  certain  that  the  pylorus  cannot  be  easily  felt, 
nor  is  the  lesser  curvature  within  reach  of  palpation,  and  if  they 
can  be  so  palpated,  they  are  in  a  condition  of  descent.  Changes 
in  the  size  of  the  stomach  within  normal  limits  are  effected  through 
the  greater  curvature. 

The  surgeon  is  inclined  to  look  at  the  function  of  the  stomach 
as  being  largely  mechanical;  it  acts  as  a  reservoir  in  which  the 
ingesta  are  macerated  in  a  weak  solution  of  pepsin  and  hydro- 
chloric acid,  breaking  up  the  food-masses,  equalizing  the  tem- 
perature, and,  with  its  powerful  muscular  apparatus,  slowly 
propelling  its  contents  into  the  small  bowel,  the  pyloric  sphincter 
acting  to  prevent  intestinal  overloading. 

Bacteria  do  not  thrive  in  the  stomach.  The  experiments  of 
Gushing  go  to  show  that  the  germs  of  the  upper  intestinal  tract 
are  of  far  less  virulence  than  in  the  lower  bowel,  and  by  proper 
cleansing  of  the  teeth  and  mouth  and  cooking  of  the  food  a  rela- 
tively high  degree  of  sterilization  can  be  secured. 


SOME    DISEASES    COMMON"    TO    TlIK    STOM ATM  1 '^.'5 

MelJiixh  of  Kxainination. — In  .sj>iU'  of  llie  (jpliiiiisin  of  the 
gastrologist,  the  value  of  the  examination  of  test-meals  and  the 
various  methods  of  absorption  for  estimating  the  motor  power  of 
the  stomaeji  are  not  ^'reat,  and  only  when  taken  into  consideration 
with  the  history  and  clinical  si<;;ns  have  they  any  real  weifj;ht.  The 
general  tendency  is  to  rely  too  much  upon  the  results  of  laboratory 
analysis  and  too  little  on  the  ordinary  clinical  examination.  While 
not  wishing  to  minimize  the  importance  of  such  analysis,  as  con- 
firmatory evidence  I  would  emphasize  the  fact  that  the  history 
and  clinical  course  are  of  first  consideration.  The  laboratory 
must  go  hand  in  hand  with  clinical  observation.  The  surgeon  is 
concerned  with  certain  definite  conditions  largely  mechanical,  or 
at  least  in  which  there  is  a  demonstrable  change  in  the  organ  itself, 
and  these  changes  are  usually  capable  of  clinical  demonstration. 
For  instance,  the  salol  test  for  loss  of  motor  power  is  unreliable, 
but  the  finding  of  food  in  the  fasting  stomach  regularly  seven 
hours  after  taking  is  both  practical  and  reliable,  and  if  found  four- 
teen hours  after,  indicates  stagnation  or  retention. 

For  making  the  outlines  of  the  stomach  evident  neither  the 
gastrodiaphanoscope  nor  the  gastroscope  is  of  real  use,  nor  can 
the  giving  of  bismuth  or  the  using  of  metal  sounds  for  the  purpose 
of  x-Tny  be  compared  in  efficiency  with  simple  dilatation  of  the 
stomach  with  bicarbonate  of  soda  and  tartaric  acid,  or,  what  is 
better  still,  a  stomach-tube  and  a  Davidson  s\Tinge,  with  which  it 
is  very  easy  to  distend  the  stomach  with  air,  and  if,  on  distention, 
the  lesser  curvature  and  pylorus  remain  in  a  normal  position  while 
the  greater  curvature  lies  below  the  umbilicus,  dilatation  is  evi- 
dent. If  the  pylorus  and  les.ser  curvature  are  detected  below 
the  costal  margin,  the  stomach  has  descended  and  the  distance 
between  the  lesser  and  greater  curvature  marks  the  extent  of  the 
dilatation  if  it  exists.  The  history  of  the  patient,  his  present 
condition,  and  the  chemical  and  biologic  examination  of  the 
gastric  contents,  taken  into  consideration  with  the  position  and 
size  of  the  stomach,  give  a  basis  for  diagnosis  and,  as  a  rule,  indi- 
cate whether  an  abdominal  incision  may  be  expedient.  In  the 
beginning  nearly  all  operations  on  the  stomach  are  exploratory 


124  WILLIAM   J.    MAYO 

in  character,  for  in  spite  of  the  most  elaborate  preliminary  in- 
vestigation, the  exact  condition  is  seldom  known  beforehand.  A 
median  incision  is  most  convenient  for  this  purpose,  and  through 
it  the  pylorus  and  anterior  wall  of  the  stomach  can  be  explored. 
The  posterior  wall  can  be  examined  by  passing  the  hand  behind 
the  stomach  through  an  opening  in  the  gastrocolic  omentum. 
Inspection  of  the  interior  of  the  gastric  cavity  is  more  diffi- 
cult. Tiffany  advises  an  incision  through  the  anterior  wall  of 
the  stomach,  and  with  the  hand  behind,  successive  portions  of 
its  interior  are  pressed  up  to  the  incision  and  inspected  through 
this  opening.  Maylard,  of  Glasgow,  in  a  paper  before  the  last 
International  Surgical  Congress,  August,  1900,  recommends  that 
an  incision  be  made  through  the  anterior  wall  of  the  stomach  and 
its  contents  removed  with  a  siphon  tube.  He  then  introduces  an 
old-fashioned  Ferguson  vaginal  speculum.  The  entire  interior 
can  in  this  way  be  inspected  mth  ease.  This  suggestion  of  May- 
lard's  is  of  great  importance  in  the  recognition  of  ulceration  and 
new-growths,  and  gives  a  certainty  to  the  diagnostic  incision  which 
it  did  not  previously  possess.  For  emptying  the  stomach  at  the 
time  of  operation  of  its  fluid  contents  we  have  found  an  ordinary 
Davidson  syringe  with  a  piece  of  gauze  tied  over  its  suction  end 
as  a  strainer  to  be  most  valuable. 

Ulcer  of  the  Stomach. — Syphihtic  and  tuberculous  ulcerations 
occur  so  rarely  as  to  be  of  small  interest.  Until  within  the  last  five 
years  surgery  was  directed  more  to  the  relief  of  secondary  conditions, 
such  as  contractions  arising  during  the  heahng  process,  or  to  the 
occasional  emergency  operation,  in  which  the  sudden  perforation 
of  a  gastric  ulcer  demanded  instant  action.  These  were  operations 
of  necessity  and  were  life  saving,  but  with  the  advent  of  better 
knowledge  of  the  subject  and  better  technic  operations  of  expedi- 
ency have  become  frequent,  with  the  intention  of  arresting  a  dis- 
tressing and  dangerous  malady  and  bringing  about  a  speedy  and 
certain  recovery. 

It  is  still  an  unsettled  question  as  to  when  the  emancipation 
and  pain  of  a  chronic  intractable  ulcer  of  the  stomach  demand 
surgical  relief.     The  problem  is  one  in  which  the  experience  of 


SOME    DISEASES    COMMON'    TO    THK    STOMACH  1 'io 

the  operator  is  llic  most  iinporlaiit  factor.  The  results  ol"  ojxt- 
ations  for  pislric  ulcer  are  constantly  iuiproviu^';  Rodman  says 
that  "in  the-  l)c<,nnning  a  new  operation  must  demonstrate  the 
reasons  for  its  existence  by  saving  the  otherwise  hopeless  cases, 
and  the  early  mortality  is  high;  later,  by  a  judicious  selection,  the 
results  are  greatly  improved." 

It  may  be  said  at  this  time  that  prolonged  and  imsucccssful 
medical  treatment  is  not  for  the  best  interest  of  the  patient.  Ger- 
hardt  states  that  28  per  cent,  of  the  cases  of  gastric  ulcer  treated 
medically  eventually  prove  fatal.  Leube,  of  Wiirzl)urg,  in  the 
tabulation  of  1000  cases  of  gastric  ulcer,  gives  a  direct  mortality  of 
4  per  cent,  from  hemorrhage  or  perforation  and  21  per  cent,  were 
not  cured.  It  is  probable  that  about  75  per  cent,  can  be  cured  by 
medical  and  dietetic  treatment  in  from  four  to  five  weeks.  Eighty- 
five  per  cent,  of  the  cases  which  cannot  be  cured  by  medical  treat- 
ment can  be  cured  by  operation. 

The  diagnosis  of  ulcer  of  the  stomach  in  the  average  ca.se  is 
easy.  The  pain,  vomiting  of  food  with  hyperacid  secretions, 
occasional  small  hemorrhages,  and  such  objective  signs  as  a  sensi- 
tive epigastric  or  dorsal  point,  all  aid  in  the  differentiation.  Hut 
it  should  not  be  forgotten  that  ulcer  may  give  rise  to  but  few  symp- 
toms, and  obstructive  dilatation  may  be  the  first  evidence  that  an 
ulcer  has  ever  existed.  Age  is  not  so  important  a  factor  as  has 
been  supposed;  I  have  watched  a  number  of  cases  in  which  active 
sym])toms  were  present  in  the  fourth  and  fifth  decades  of  life,  and 
in  two  instances  have  operated  to  cut  short  its  course  after  the 
fortieth  year.  The  presence  of  a  tumor  was  long  considered  a 
differential  sign  as  against  ulcer.  A  thickening  over  an  ulcerated 
area  may  sometimes  be  felt,  and  occasionally  with  great  ease. 

For  chronic  intractable  ulceration  three  methods  of  ojjcration 
have  been  practised:  Excision,  incision  with  suture,  and  gastro- 
enterostomy. Each  has  its  proper  indication  and  field  of  useful- 
ness. Gastro-enterostomy  relieves  the  hyperchlorhydria  and  puts 
the  stomach  at  rest,  and  if  more  than  one  ulcer  is  present,  it  is  the 
operation  of  choice.  Xicolaysen  has  gathered  30  cases  from  the 
literature   successfully   treated    in    this    manner.     In   5   cases   of 


126  WILLI.^1   J.    MAYO 

our  ovm  the  results  of  gastro-enterostomy  for  the  rehef  of  open 
ulcer  were  satisfactory,  but  not  speedy.  In  each  case  six  months 
or  more  elapsed  before  the  symptoms  were  relieved.  The  con- 
tracted stomach  seemed  to  be  unable  to  hold  enough  nourishment, 
and  the  opinion  of  Malthe  that  a  number  of  months  of  painful 
digestion  is  to  be  expected  after  gastro-enterostomy  for  open  ulcer 
has  been  borne  out  by  our  experience.  Excision  has  been  prac- 
tised in  a  small  number  of  cases.  To  do  this  successfully  requires 
that  the  ulcer  be  single  and  in  an  accessible  situation.  In  any 
operation  for  intractable  ulcer  great  care  should  be  exercised  in 
handling  adlierent  portions  of  the  stomach-wall,  as  under  such 
circumstances  partial  gastrectomy^  may  become  necessary  to 
prevent  secondary  perforation. 

At  least  6  per  cent,  of  all  gastric  ulcers  perforate  (Finney),  and 
of  56  cases  of  perforation  collected  by  Dickinson  from  the  St. 
George's  Hospital  reports,  about  one-half  died  at  once  and  one-half 
formed  adhesions,  with  resulting  abdominal  or  subphrenic  abscess, 
fistula,  or  other  secondary  complications.  The  result  depends 
upon  the  suddenness  of  the  perforation,  its  location,  and  the  amount 
of  the  gastric  contents  at  the  time,  ulcers  on  the  lesser  curvature 
and  posterior  surface  being  more  liable  to  be  at  least  temporarily 
protected  by  adhesions.  In  793  perforated  cases  Welch  found 
62  per  cent,  on  the  lesser  curvature  and  the  posterior  wall. 

The  treatment  of  acute  perforation  is  immediate  suture  wdth 
omental  graft,  or,  if  necessary,  gauze  isolation  and  drainage.  Sec- 
ondary processes  the  result  of  perforations  should  be  cared  for  on 
ordinary  surgical  principles.  Tinker  has  collected  268  cases  of 
perforation,  which  have  been  operated  upon  vnih  48  per  cent, 
mortality.  Perforation  of  ulcer  in  the  first  portion  of  the  duo- 
denum has  been  sho^Ti  by  Weir  to  be  not  an  infrequent  accident, 
and  in  its  course  and  results  not  to  differ  materially  from  gastric 
perforation,  except  that  it  gives  rise  to  a  right-sided  peritonitis 
resembhng  a  cholecystitis  or  appendicitis,  and,  as  Richardson  has 
pointed  out,  the  result  in  either  gastric  or  duodenal  perforation 
depends  largely  on  the  quantity  of  fluid  turned  loose  in  the  abdom- 
inal cavity,  as  well  as  the  speed  and  thoroughness  with  which  it 


SOME   DISEASES   COMMON    TO   THE    STOMAril  l'-27 

is  removed.  Finney  again  (alls  attention  to  the  sudden  increase 
in  the  leukocyte  count  as  an  early  symptom  of  perforation  of  the 
stomach,  and  says  that  in  this  resjjcct  it  is  similar  to  typhoid 
perforation. 

Hemorrhage  the  result  of  gastric  ulcer  may  demand  surgical 
intervention.  Repeated  small  hemorrhages  are  perhaps  a  more 
positive  indication  for  operation  than  a  single  large  hemorrhage. 
Such  cases  have  been  treated  by  Kiister  and  others  by  primary 
incision,  or  with  the  actual  cautery  and  gastro-enterostoray. 
Andrews  and  Eisendrath  have  elaborated  a  definite  operation  for 
the  treatment  of  hemorrhage  from  gastric  ulcer.  Through  an 
incision  into  the  gastric  cavity  the  bleeding  point  is  located  and 
tied  en  masse  from  within,  protective  sutures  being  introduced 
from  without  if  possible.  Gastro-enterostomy  is  perhaps  most 
often  performed  of  necessity,  and  frequently  the  bleeding  point  can- 
not be  located  even  at  postmortem,  or  several  ulcers  may  be  present ; 
fortunately,  the  hemorrhage  is  usually  checked  by  this  operation. 

The  most  common  indication  for  operation  following  ulcer  is 
obstruction,  the  result  of  the  healing  process,  with  subsequent 
dilatation.  This  usually  occurs  at  the  pylorus,  but  may  take 
place  in  the  body,  and  an  hour-glass  distortion  of  the  stomach 
result.  The  latter  form  is  not  common.  Watson  found  but  29 
operated  cases  in  the  literature,  including  two  of  his  own.  In 
hour-glass  stomach  two  general  plans  of  attack  have  been  adopted : 
first,  gastro-enterostomy  with  attachment  to  the  proximal  pouch. 
Unfortunately,  this  does  not  drain  the  distal  cavity.  Second,  a 
plastic  operation,  in  which  the  two  pouches  are  joined;  for  many 
reasons  the  latter  is  the  preferable  operation. 

Pyloric  obstruction  the  result  of  contraction  is  a  frequent 
condition,  and  not  so  often  diagnosticated.  The  diagnosis  is 
that  of  dilatation  of  the  stomach  with  retention,  and  such  com- 
plications as  the  accompanying  chronic  gastritis  may  give  rise 
to — hyperchlorhydria,  supersecretion,  and  so  forth. 

For  the  relief  of  benign  obstructions,  pyloroplasty  and  gastro- 
enterostomy have  been  rival  procedures.  The  first  requires  that 
the  amount  of  scar  tissue  be  small,  otherwise  a  plastic  operation 


128  WILLIAM   J.    MAYO 

is  hazardous,  and,  secondly,  that  the  hypertrophy  of  the  muscular 
coat  be  equal  to  the  task  of  elevating  the  food  from  the  artificial 
pouch  of  the  dilated  stomach.  These  conditions  are  seldom 
present,  and  nearly  one-half  of  the  pyloroplasties  eventually  require 
gastro-enterostomy  for  relief.  The  latter  operation  is  more 
reliable,  but  has  a  slightly  higher  mortality.  In  11  pyloroplasties 
all  recovered,  but  we  were  later  compelled  to  do  a  gastro-enteros- 
tomy in  4.  In  41  gastro-enterostomies  for  various  causes  the 
operation  was  a  mechanical  success  in  all,  but  5  died. 

Some  Forms  of  Gastrectasia  of  Uncertain  Origin. — There  are  a 
number  of  cases  of  dilatation  of  the  stomach  in  which,  if  there  is  an 
obstruction,  it  is  not  discoverable.  The  symptoms  are  not  unlike 
obstructive  dilatation  in  the  severe  cases,  while  in  the  milder 
forms  the  condition  is  that  of  an  ordinary  dyspepsia.  The  causa- 
tion is  obscure,  although  most  frequently  ascribed  to  constitu- 
tional maladies  and  wasting  diseases,  yet  it  is  not  uncommon  in 
people  who  are  otherwise  robust,  and  in  these  cases  is  supposed 
to  be  a  neurosis.  If  compensatory  hypertrophy  of  the  gastric 
muscles  takes  place,  the  peristaltic  waves  can  be  seen  as  the 
stomach  contracts.  In  other  cases  no  such  hypertrophy  exists, 
and  the  muscular  coat  is  thinned  and  stretched  without  visible 
signs  of  its  action  at  any  time.  In  this  way,  then,  I  think  we  can 
distinguish  two  general  classes:  in  the  first,  obstruction  to  easy 
passage  must  exist,^ — the  hypertrophy  proves  it, — and  in  the 
second  the  absence  of  hypertrophy  indicates  some  other  origin. 
In  analyzing  the  first  group  of  cases  the  position  of  the  pylorus  is 
important.  I  have  a  number  of  times  noticed  that,  with  other 
conditions  equal,  if  the  pylorus  was  at  a  low  point,  dilatation  did 
not  come  on  so  early  nor  so  completely  as  when  the  outlet  was  at 
a  high  level. 

In  a  paper  read  before  the  American  Medical  Association  in 
1895  I  described  a  form  of  obstruction  of  the  pylorus  called  "valve 
formation,"  in  which  a  high-lying  and  fixed  pylorus  became  more 
and  more  compressed  as  the  stomach  filled,  the  distention  finally 
relieving  itself  by  copious  vomiting  of  the  retained  ingesta.  In 
these  cases  there  is  the  constant  need  of  elevating  the  food  up- 


SO.MK    DISKASK.S    COMMON    TO    THE    STOMACH  1 '29 

ward,  with  rcsultjuit  liyportro[)liy,  but  without  diminution  of  the 
caHber  of  tlie  pyloric  opening.  Any  sHght  overloading  causes  an 
acute  angle  at  the  outlet  and  interferes  with  the  delivery  of  the 
food  into  the  duodenum.  I  believe  this  is  often  a  cause  of  dilata- 
tion, and  have  oj)cratcd  on  four  such  cases.  The  so-called  "fish- 
hook" i)ylorus,  in  which  the  pyloric  opening  is  directed  upward, 
increasing  the  muscular  efforts,  acts  in  a  similar  manner  by  in- 
creasing the  work. 

Spasm  of  the  {)ylorus  has  been  a  popular  diagnosis  of  late,  and 
is  supposed  to  depend  upon  an  ulceration  which  may  be  too  slight 
to  be  seen,  yet  sufficient  to  cause  a  spasmodic  closure  of  the  pylorus, 
interfering  more  or  less  with  the  passage  of  the  gastric  contents. 
I  have  met  with  four  cases  in  which  this  appeared  to  be  the  condi- 
tion. The  pyloric  sphincter  w^as  tightly  contracted  in  each,  and 
on  the  under  surface  a  thickening  could  be  felt.  In  two  there  were 
slight  adhesions,  and  in  three  there  was  some  glandular  enlarge- 
ment. The  pylorus  was  opened  longitudinally  in  all,  and  the 
pyloric  region  carefully  examined;  in  one  a  small  ulcer  could  be 
seen;  in  two  there  seemed  to  be  an  erosion  of  the  mucous  coat;  in 
one  nothing  could  be  found.  In  all  these  cases  there  was  hj^po- 
chlorhydria  or  supersecretion.  In  each  case,  on  opening  the  gastric 
cavity  a  quantity  of  clear  mucus  and  gastric  secretions  were  en- 
countered, but  not  much  evidence  of  decomposing  food,  differing 
in  this  respect  markedly  from  cicatricial  contraction.  In  each 
case  the  diagnostic  incision  was  closed  transversely  by  pyloroplasty. 
In  all  these  cases  there  was  temporary  relief,  but  in  two  it  was 
necessary  to  do  a  gastro-enterostomy  later.  The  previous  history 
of  the  cases  was  similar — a  rather  sudden  commencement,  pain 
a  constant  symptom,  aggravated  liy  eating,  loss  of  flesh,  hj-per- 
chlorhydria,  or  supersecretion.  Test-meals  showed  excessive 
acidity  and  a  somewhat  dilated  stomach,  but  without  much 
retention  of  food.  In  two  the  pain  was  just  beneath  the  ensiform 
cartilage;  in  two  so  far  to  the  right  as  to  suggest  gall-stone  disease, 
and  they  were  operated  upon  with  this  diagnosis.  It  is  possible 
that  these  cases  are  similar  to  fissure  of  the  anus  in  the  painful 
spasm  produced.     All  these  patients  starved  themselves  rather 

VOL.  1—9 


130  wiLLL^ii  J.  :nl\yo 

than  endure  the  certain  pain  which  followed  eating,  yet  in  none 
was  vomiting  a  prominent  symptom.  The  pyloroplasties  in 
which  rehef  did  not  follow  the  operation  were  found  to  be  adherent 
at  a  high  level.  In  four  cases  since  then  I  have  fastened  the 
pylorus  at  a  low  point  to  the  abdominal  wall  after  pyloroplasty. 
hoping  that  this  might  relieve  the  mechanical  condition  and 
enable  the  stomach  to  drain  to  better  advantage.  Whether 
this  will  prove  true  cannot  yet  be  determined.  Pyloric  spasm 
as  an  explanation  of  the  obstructive  phenomena  in  certain  cases 
is  very  alluring;  it  is  not  necessary  that  anything  should  be  found 
on  exploration,  the  inference  being  that  the  spasm  relaxes  under 
the  anesthetic,  and  the  ulcer  is  too  small  to  be  apparent.  That 
this  condition  does  exist  cannot  be  doubted,  but  we  should  be 
careful  not  to  make  it  a  "scapegoat"  for  other  more  material  causes. 
Gastroptosis  may  also  cause  dilatation,  and  the  two  difficulties 
not  infrequently  coexist.  In  such  cases  the  pylorus  is  prolapsed 
downward  and  to  the  right:  the  lesser  curvature  is  in  e\-idence 
below  the  margin  of  the  ribs,  but  the  greater  curvature  is  propor- 
tionately much  lower,  rendering  the  relative  position  of  the  pylorus 
such  as  to  necessitate  an  increased  muscular  effort  to  force  the 
food  on  its  journey  into  the  small  bowel.  Gastroptosis  is  usually 
a  part  of  a  general  condition  associated  with  a  prolapse  of 
the  abdominal  viscera,  and  for  which  no  adequate  explanation 
has  yet  been  advanced.  There  are  at  least  two  factors  which 
may  be  causative:  a  loss  of  muscular  tone  and  neurasthenia, 
although  the  latter  is  sometimes  considered  a  result  rather  than 
a  cause.  There  are  two  varieties  of  cases  in  which  no  h^-per- 
trophj^  exists.  The  first  may  be  said  to  be  a  secondary  dila- 
tation, the  obstruction  causing  a  primary  h\'pertrophy  and 
finally,  increasing  beyond  the  hniits  of  compensation,  the  muscular 
coats  of  the  stomach  become  thinned  and  stretched  under  the 
increased  strain.  The  second  variety  is  where  myasthenia  exists 
without  obstruction,  seemingly  due  to  a  simple  atony.  The 
resulting  retention  causes  dilatation  and  aU  its  disastrous  com- 
plications. Gastric  myasthenia  is  usually  a  chronic  affection. 
yet  sometimes  occurs  in  a  most  acute  form,  the  dilatation  pro- 


SOME    DISEASES    COMMON    TO    THE   STOMACH  1 '5 1 

ducing  violent  symptoms  ami  f^cnorally  irsiilling  in  death  in  a 
few  days.  Without  rej^ard  to  its  origin,  dilatation  causes  a  number 
of  symptoms  common  to  all.  Tlie  stomach  is  shown  to  he  too 
large  by  distention  with  air,  splashing  sounds,  and  other  signs, 
the  subjective  .symptoms  depending  on  the  degree  of  retention 
and  its  effect  on  the  gastric  mucosa.  Chronic  inflammation  of 
the  mucosa  usually  coexists,  due  to  the  .stagnation  and  fermenta- 
tion; supersecretion  or  hyperchlorhydria  may  be  present,  the 
result  of  the  hyperasthenic  gastritis.  The.se  .symptoms  are  of 
great  clinical  importance,  and  w'orthy  of  more  attention  than  the 
scope  of  this  pa])er  permits. 

Supersecretion  and  hyperchlorhydria  are  conditions  closely 
connected  with  pyloric  spasm,  either  as  cause  or  effect,  and  may 
be  sufficiently  pronounced  and  the  effects  on  the  individual  so 
unfortunate  as  to  demand  surgical  intervention.  In  these  cases 
drainage  of  the  stomach  would  be  indicated  whether  dilatation 
exists  or  not.  Many  individuals  suffering  from  dilatation  eat  so 
carefully  and  so  little  as  to  maintain  a  balance  w'ith  the  compensa- 
tion;  in  other  cases  drainage  of  the  stomach  pouch  is  desirable. 

Gastro-enterostomy  is  most  generally  useful,  and  has  few  con- 
traindications. The  opening  should  be  established  at  or  near  the 
greater  curvature,  and  this  is  of  great  importance  in  securing 
adequate  drainage  and  preventing  regurgitant  vomiting.  Whether 
the  suture  or  button  is  used  or  the  anterior  or  posterior  operation 
employed  makes  little  difference  in  the  result,  provided  the 
anastomotic  opening  be  placed  at  the  bottom  of  the  pouch  of  the 
stomach.  Pyloroplasty  may  be  of  benefit  in  certain  cases;  as  a 
result  of  my  own  experience  I  believe  that  much  depends  on  the 
position  of  the  pylorus.  If  the  outlet  is  high,  the  weakened 
muscles  must  still  elevate  the  food,  and  relapse  after  pyloro])lasty 
may  occur;  on  the  contrary,  if  the  pylorus  lies  low,  gravity  aids 
its  progress.  Gastroplication  endeavors  to  overcome  this  necessary 
elevation  of  food  by  i)laiting  the  walls  of  the  gastric  pouch  so 
as  to  change  the  relative  position  of  the  pylorus.  It  may  be 
advantageous  in  selected  cases  if  the  pyloric  opening  is  ample, 
but  personally  I  have  never  met  with  a  case  in  whiih  this  opera- 
tion appeared  to  be  indicated. 


SOME    INDICATIONS     FOR    GASTRO- 
ENTEROSTOMY* 

WILLIAM    J.    MAYO 


Surgery  of  the  stomach  has  advanced  rapidly  and  now  occupies 
a  secure  position.  Its  Hmitations,  however,  are  not  as  yet  estab- 
lished, and  there  is  much  debatable  ground  between  the  internist 
and  the  surgeon.  This  is  more  especially  true  of  the  inflammatory 
condition  of  the  stomach,  of  which  ulcer  is  the  more  common.  It 
would  be  manifestly  impossible  for  me  to  cover  the  entire  ground 
of  gastric  surgery  in  the  short  time  at  my  disposal,  and  I  shall, 
therefore,  confine  myself  to  one  phase  of  the  subject — that  of 
gastric  drainage  by  means  of  gastro-enterostomy. 

Dilatation  of  the  stomach  is  not  a  disease,  but  a  symptom,  yet 
the  ease  with  which  it  can  be  diagnosed  and  the  desirability  of  its 
relief  without  regard  to  cause  render  it  a  factor  of  prime  import- 
ance. The  original  operation  of  gastro-enterostomy  as  performed 
by  Wolfler  in  1881  had  this  object  in  view.  Pyloric  obstruction 
due  to  cancer  not  amenable  to  radical  operation  gives  a  clear  indi- 
cation for  gastro-enterostomy,  and  as  much  can  be  said  of  the  benign 
forms  of  obstruction,  such  as  the  healing  of  an  ulceration  in  the 
vicinity  of  the  pylorus.  The  relation  between  cause  and  effect  is 
apparent,  and  the  argument  is  simple  and  convincing.  Gastro- 
enterostomy for  the  relief  of  open  ulcer  and  allied  inflammatory 
conditions  without  obstruction  develops  a  new  line  of  thought  and 
there  is  room  for  discussion.  All  in  all,  this  operation  is  by  far 
more  valuable  than  any  other  operative  procedure  upon  the 
stomach.  In  136  operations  on  the  stomach  performed  in  St. 
Mary's   Hospital,    more   than    half    have   been   gastro-enteros- 

*Reprinted  from  "The  St.  Paul  Medical  Journal,"  November,  1901. 

132 


SOME   IN1)1(  ATIOXS    KOU   (JASTRO-ENTEROSTOMY  133 

toiiiies,     and    our    experience    lias    Ik'cii    that    of    o])erator.s    in 
widely  different  fields. 

Cancer  of  the  Stomach 

In  somewhat  over  100  cases  of  malignant  disease  of  the  stomach 
which  the  writer  has  examined  with  a  view  to  surgical  operation, 
more  than  half  wore  so  plainly  advanced  beyond  radical  interven- 
tion that  exploration  was  not  necessary  to  ascertain  the  fact. 
In  spite  of  the  most  elaborate  examination  of  the  stomach-con- 
tents and  other  methods  of  diagnosis  it  has  been  only  those  cases 
in  which  the  location  of  the  growth  introduced  mechanical  features 
that  a  diagnosis  could  be  made  sufficiently  early  to  make  an  at- 
tempt to  cure  by  a  radical  operation. 

One  of  the  most  pronounced  symptoms  of  gastric  carcinoma  is 
the  diminished  muscular  power  of  the  stomach,  and  if  the  growth 
be  pyloric,  a  small  amount  of  obstruction  gives  early  evidence  of  its 
presence.  Adequate  compensatory  hypertrophy  is  not  found,  al- 
though present  to  a  marked  degree  in  non-malignant  obstruction. 
The  great  difficulty  in  making  an  early  diagnosis  in  malignant 
disease  renders  gastro-enterostomy  the  operation  most  often  indi- 
cated. It  is  to  be  hoped  that  in  the  future  an  earlier  diagnosis 
may  more  frequently  enable  radical  operations  to  be  performed. 

In  53  operated  cases  of  cancer  of  the  stomach  we  have  made 
gastro-enterostomy  18  times,  with  4  deaths.  The  longest  period 
of  life  after  gastro-enterostomy  was  nineteen  months,  with  ability 
to  work  until  a  few  weeks  prior  to  death.  Excision  of  the  pylorus 
and  a  greater  or  less  amount  of  the  stomach  was  undertaken  11 
times,  with  1  death;  6  patients  are  still  alive,  and  1  of  these 
nearly  four  years,  although  there  arc  now  evidences  of  metastasis  in 
the  liver  in  this  case.  In  the  remaining  cases  the  extent  of  the 
disease  or  location  not  giving  rise  to  obstructive  phenomena,  op- 
eration was  not  indicated,  and  the  abdominal  incision  was  closed. 
For  the  past  five  years  we  have  sutured  exploratory  abdominal  in- 
cisions for  inoperable  malignant  disease  with  permanent  sutures  of 
buried  silk  or  silver  wire.  This  enables  the  patient  to  get  about 
the  next  day  and  leave  the  hospital  \\'ithin  the  week.     If  left  in 


13i  WILLIAM   J,    MAYO 

bed  the  usual  length  of  time,  many  of  these  patients  become  pro- 
gressively weaker  and  are  unable  to  return  to  their  homes  and 
friends. 

The  mortality  of  gastro-enterostomy  for  malignant  disease  is 
20  per  cent,  or  over — fully  as  high  as  after  pylorectomy.  The 
first  requirement  for  the  performance  of  a  radical  operation  is  that 
the  disease  should  not  be  too  far  advanced,  and  the  patient  must  be 
in  good  condition.  Gastro-enterostomy  has  no  such  limitations,  and 
the  mortality  is  influenced  to  a  large  extent  by  the  condition  of  the 

patient. 

Ulcer 

Excision  or  other  form  of  surgical  treatment  is  indicated  in  a 
few  cases  presenting  special  features,  but  the  common  situation  of 
the  ulceration,  its  varying  extent,  and  the  reasonable  possibility 
that  more  than  one  ulcer  exists,  make  gastro-enterostomy  the  prac- 
ticable operation  in  the  majority  of  cases.  Not  infrequently  the 
site  of  the  ulcer  cannot  be  discovered,  rendering  gastro-enterostomy 
the  operation  of  necessity. 

The  symptoms  of  ulcer  of  the  stomach  depend  somewhat  upon 
the  situation  of  the  disease;  ulcer  is  most  common  near  the  pylorus, 
a  position  which  may  introduce  certain  mechanical  features,  and  it 
is  in  the  relief  of  these  secondary  phenomena  that  this  operation 
achieves  its  triumphs.  Gastro-enterostomy  relieves  the  hyper- 
acidity and  allows  prompt  emptying  of  the  ingesta,  preventing  irri- 
tation and  aiding  nutrition. 

The  ulcerated  stomach  is  often  contracted,  and  among  the 
earlier  observers  it  was  supposed  to  be  always  small;  this  is  partly 
true.  In  acute  ulcer  the  stomach  is  small,  and  if  the  ulcerative  proc- 
ess is  not  in  the  vicinity  of  the  outlet,  it  will  probably  remain 
small.  On  the  contrary,  it  is  during  the  healing  process  that  many 
ulcers  in  the  pyloric  region  become  most  troublesome.  Ulcers  in 
this  situation  are  often  extensive,  and  in  chronic  cases  perhaps  but 
partly  cicatrized.  Enough  distortion  or  narrowing  of  the  pyloric 
outlet  takes  place  materially  to  obstruct  the  opening,  the  unhealed 
portion  of  the  ulcer  keeping  up  irregular  symptoms  of  its  presence 
in  addition  to  the  dilatation.     In  such  cases  symptoms  of  open  ulcer 


SO.Mi;    INDICATIONS    FOR    GASTRO-ENTEROSTOMY  135 

alternate  with  periods  of  health,  and  later  signs  of  ulc-er  in  a  stomach 
more  or  less  dilated  supervene.  The  majority  of  cases  when  once 
cicatrized  remain  healed,  but  a  minority  occasionally  lapse  into  open 
ulcer.  The  capacity  of  the  stomach  affected  hy  ulcer  is  not  greatly 
changed  in  the  majority  of  cases,  hut  if  so,  it  has  a  surgical  signifi- 
cance. This  gives  us  a  good  working  basis  of  comparison.  First, 
ulcers  in  the  i)yloric  region,  with  a  normal  or  enlarged  stomach, 
and,  second,  ulcers  in  a  contracted  stomach. 

In  the  first  group  gastro-enterostomy  is  the  operation  of 
choice:  it  delivers  the  ingesta  at  a  point  sufficiently  far  from  the 
disease  to  prevent  irritation,  and  the  healing  process  is  not  inter- 
fered with  and  progresses  rapidly.  We  have  made  gastro-enteros- 
tomy 11  times  for  this  condition,  with  1  death;  the  remaining  10 
were  cured  and  remain  well.  At  times  a  small  ulcer  at  the  pylorus 
causes  pyloric  spasm,  and  symptoms  are  produced  resembling  me- 
chanical interference.  In  four  cases  of  pyloric  spasm  we  found  di- 
latation only  once,  and  then  not  at  all  marked.  In  this  form  of 
disease  pyloroplasty  is  fairly  effective,  but  does  not  compare  with 
the  benefits  derived  from  gastro-enterostomy  in  suitable  cases,  al- 
though the  division  of  the  pyloric  sphincter  stops  the  spasm  and 
the  enlargement  of  the  opening  exerts  a  healing  influence  on  the 
ulcer. 

In  the  second  group  of  cases  gastro-enterostomy  does  not  give 
immediate  relief,  as  a  rule.  In  four  cases  of  our  own  the  symptoms 
in  a  modified  degree  continued  for  some  months.  However,  ex- 
perience goes  to  show  that  after  gastro-enterostomy  the  ulcer  will 
eventually  heal,  but  the  results  are  not  so  good  as  in  the  first  group 
of  cases.  The  pylorus  being  open  and  the  stomach  small,  it  is  self- 
evident  that  the  main  function  of  gastro-enterostomy  is  already 
well  performed,  and  it  is  probable  that  in  some  cases  the  artificial 
opening  will  not  remain  patent.  In  two  of  these  four  cases  secon- 
dary kinking  of  the  small  bowel  at  the  anastomotic  opening  caused 
symptoms  of  chronic  obstruction,  and  in  both  the  communication 
was,  at  the  second  operation,  found  to  be  much  reduced  in  size. 
In  one  case  but  six  weeks  elapsed,  in  the  other,  thirteen  months. 
Theoretically,  we  would  expect  the  opening  to  close  in  this  group  of 


136  WILLLAJM   J,    MAYO 

cases,  the  pylorus  being  of  good  caliber  and  the  stomach  properly 
emptying  itseK,  the  fistula  becomes  cicatrized  from  non-use.  In 
the  contraction  attending  closure  in  these  cases  the  attached  in- 
testine was  angulated,  causing  distress.  Entero-anastomosis  be- 
tween the  two  limbs  of  the  attached  intestine  afforded  prompt 
relief.  Taken  alone,  this  would  seem  to  contraindicate  gastro- 
enterostomy on  the  small  stomach,  which  would  not  be  just, to 
the  operation,  since  both  of  these  cases  were  cured  of  the  ulcera- 
tion, as  shown  at  the  second  operation.  The  temporary  arrest  of 
activity  in  the  stomach  and  prompt  drainage  of  ingesta  allow  speedy 
healing  of  the  ulcer.  It  must  also  be  borne  in  mind  that  these 
cases  represent  the  chronic  and  intractable  variety  of  ulceration. 
The  majority  of  dilated  stomachs  are  due  to  old  ulcers  which  have 
permanently  closed,  and  only  the  mechanical  interference  with  the 
progress  of  the  food  remains. 

Benign  Obstruction  at  the  Pylorus 
Pyloric  obstruction  of  benign  origin  is  usually  the  result  of 
the  healing  of  an  ulceration  in  the  vicinity  of  the  pylorus.     In 
some  cases  it  is  due  to  valve  formation. 

Obstruction  from  without  the  stomach,  due  to  pressure  of  tu- 
mors or  adhesions,  may  also  be  an  indication  for  operation.  In 
some  cases  a  dilated  stomach  is  found  without  apparent  obstruc- 
tion, but  as  the  muscular  wall  is  often  greatly  increased,  we  may 
take  it  that  some  interference  with  prompt  emptying  of  the  gastric 
cavity  exists.  Non-malignant  obstruction  of  the  pylorus  is  usually 
accompanied  by  marked  hypertrophy  of  the  stomach-wall,  with 
dilatation  in  the  later  stages,  which  may  be  aptly  compared  to  the 
heart  with  valvular  insufficiency.  Most  of  these  patients  eat 
little,  and  unconsciously^  try  to  accommodate  the  food  quality  and 
quantity  to  the  diminished  gastric  musculature.  Others  wash  the 
residue  out  of  the  stomach  with  a  stomach-tube.  Vomiting  is  not 
so  common  in  these  cases  as  in  those  more  acute  in  character,  al- 
though in  the  later  stages  vomiting  of  large  quantities  is  to  be  ex- 
pected. A  peculiarity  about  some  of  these  cases  is  the  formation 
of  a  gastric  pouch,  due  to  the  more  rapid  stretching  of  the  greater 


HOME    INDICATIONS    FOR   GASTRO-ENTEROSTOMY  Itil 

curvature.  It  is  for  Lliis  rcuson  lliut  pyloroplasty  may  fail  to  cure. 
The  pylorus  being  held  high,  even  if  the  opening  be  made  of  ample 
size,  the  fatty  degenerated  muscle-fiber  is  unable  to  elevate  the 
food  from  the  pouch,  and  the  patient  is  not  materially  relieved.  In 
15  j)yloroi)lasties  we  were  compelled  to  make  gastro-enterostomy  G 
times  as  a  secondary  operation.  It  is  in  these  advanced  cases  that 
gastro-enterostomy  gives  the  great  advantage  over  pyloroplasty. 
The  opening  can  be  made  at  the  bottom  of  the  pouch,  furnishing 
adequate  drainage. 

Hour-glass  stomach,  in  rare  instances,  may  demand  gastro- 
enterostomy upon  the  proximal  pouch.  We  had  one  such  case. 
Gastroplasty  is,  however,  the  operation  of  choice,  as  shown  by  Wat- 
son, We  have  performed  gastro-enterostomy  35  times  for  benign 
obstruction  of  various  forms,  with  1  death — this  in  a  case  of 
chronic  starvation  of  most  pronounced  character.  Analyzing  the 
67  gastro-enterostomies  upon  which  the  report  is  based,  we  find  an 
average  mortality  of  less  than  9  per  cent. — highest  in  the  malignant 
cases,  as  would  be  expected  (23  per  cent.) ;  for  open  ulcer,  about  6 
per  cent.  The  condition  of  the  average  patient  with  an  intractable 
ulceration  would  lead  us  to  expect  this  death-rate,  although  if  the 
operation  be  performed  at  an  earlier  date,  it  should  not  exceed  5  per 
cent.  In  the  benign  obstructions  which  form  more  than  one-half  of 
the  cases  only  1  death  in  35  cases,  or  less  than  3  per  cent.,  occurred. 

The  operation  has  three  points  of  interest:  Shall  it  be  made 
with  the  suture  or  with  the  Murphy  button?  This  is  a  matter 
of  individual  preference— the  results  are  about  the  same.  Another 
open  question  is  whether  the  anastomosis  should  be  made  to  the 
anterior  wall  of  the  stomach  (Wolfler)  or  to  the  posterior  (von 
Hacker).  We  have  performed  the  anterior  57  times,  with  good  re- 
sults. In  the  last  year  we  have  made  a  few  posterior — 10  in  all; 
they  have  done  as  well  in  every  respect.  The  point  of  great  import- 
ance is  that  in  either  operation  the  juncture  should  be  at,  or  near,  the 
greater  curvature  and  at  the  bottom  of  the  gastric  pouch.  By  actual 
observation  of  our  own  cases  we  found  that  the  opening,  properly 
placed,  either  anteriorly  or  posteriorly,  came  within  one-half  inch  of 
the  same  point  in  the  gastric  cavity.    The  attached  wall  of  the  stom- 


138  WILLIAM   J.    MAYO 

ach  promptly  assumes  a  funnel  shape,  and  regurgitant  vomiting  is 
seldom  seen.  Lastly,  shall  the  two  limbs  of  the  bowel  be  separately 
anastomosed  (Braun)  as  a  primary  operation?  If  the  above  method 
of  securing  a  low  union  with  the  stomach  be  carried  out,  it  is  usually 
unnecessary.  It  sometimes  happens  that  either  by  adhesions  or 
angulation  distress  will  be  occasioned  by  small  amounts  of  bile 
passing  into  the  stomach,  which  may  or  may  not  be  vomited.  I 
wish  to  call  especial  attention  to  this  condition  following  gastro- 
enterostomy. In  going  over  the  literature  it  would  seem  to  be 
met  with  only  immediately  after  operation,  frequently  causing 
death  from  the  so-called  "vicious  circle."  Carle  showed  by  ex- 
perimentation that  a  small  quantity  of  bile  was  found  in  the  stom- 
ach for  a  long  time  after  gastro-enterostomy,  but  that  it  caused 
no  trouble.  We  have  met  with  this  condition  months  after  the 
operation,  but  it  did  cause  distress,  although  not  usually  attended 
with  vomiting  of  food.  At  times  a  mouthful  of  bile-stained  fluid 
would  be  regurgitated  or  could  be  washed  out  of  the  stomach  by 
gastric  lavage.  I  am  uncertain  whether  this  is  due  to  regurgitation 
through  the  open  pylorus  or  through  the  fistula.  In  the  three 
cases  referred  to  the  operation  was  performed  for  the  rehef  of  ulcer 
with  unobstructed  pylorus.  At  the  second  operation  the  fistula 
was  found  much  reduced  in  size,  with  some  angulation.  Entero- 
anastomosis  cured  these  cases.  It  would  seem  that  primary  re- 
gurgitation of  bile  and  pancreatic  juice  could  be  prevented  by  a 
low  location  of  the  fistula,  and  that  secondary  regurgitation  would 
not  take  place  in  pyloric  obstruction,  but  with  an  unobstructed 
pylorus,  as  when  the  operation  is  done  for  open  ulcer,  entero- 
anastomosis  as  a  primary  operation  would  be  indicated  to  prevent 
these  delayed  but  unpleasant  symptoms. 

In  the  future  we  will  make  an  entero-anastomosis  in  every  case 
in  which  gastro-enterostomy  is  performed  if  there  be  no  obstruction 
of  the  pylorus.  That  this  is  clearly  indicated  is  shown  by  the 
three  secondary  operations  in  13  cases.  In  obstructed  pylorus  we 
did  not  have  a  single  instance  in  54  operations,  and  therefore  it 
could  not  be  considered  in  this,  the  larger,  group. 


PROBLEMS  RELATING  TO  SURGERY  OF  THE 

STOMACH* 

WILLIAM   J.    MAYO 


In  the  preparation  of  the  subject  to  be  discussed  I  have  thought 
it  wise  to  confine  myself  to  the  practical  aspects  of  gastric  surgery, 
using  for  this  purpose  the  material  obtained  from  a  single  hospital. 
This  method  of  treating  the  subject  is  not  due  to  a  lack  of  appre- 
ciation of  the  work  of  the  pioneers  in  this  branch  of  our  art.  but 
rather  with  the  hope  that  the  limited  experience  of  an  observer  in 
a  somewhat  distant  field  might  be  of  greater  interest. 

Gastric  surgery,  to  a  large  extent,  is  still  in  the  developmental 
stage,  and  this  is  due  to  the  lack  of  definite  knowledge  upon  which 
to  base  a  surgical  diagnosis.  Volumes  have  been  written  upon 
diseases  of  the  stomach  from  a  medical  standpoint,  but  as  the  state- 
ments made  are  based  upon  the  symptoms  of  the  patient  or  the 
results  of  postmortem  examinations,  we  gain  but  little  in  that  great 
middle  ground  in  which  the  surgery  of  expediency  will  find  its  field 
of  usefulness.  The  debatable  territory  is  now  being  explored,  and 
we  shall  shortly  have  more  exact  knowledge  concerning  it.  Our 
own  experience  would  seem  to  indicate  that  in  the  medical  diag- 
nosis there  are  four  important  lines  of  inquiry  to  be  pursued:  (1) 
The  history  of  the  patient;  (2)  the  size  and  position  of  the  stomach; 
(3)  or  tumor  localizing  point  of  tenderness;  (4)  interference  with 
the  progress  of  the  food.  The  examination  of  the  stomach-contents 
has  corroboratory  value,  especially  with  reference  to  the  stagna- 
tion or  retention  of  ingesta.     The  chemical  and  microscopic  find- 

*  Read  before  the  Surgical  Section  of  the  Suffolk  District  Medical  Society, 
February  iG,  \{)0i.  Reprinted  from  "Boston  Medical  and  Surgical  Journal," 
May  1.  hoi,  vol.  cxlvi.  \o.  18,  pp.  451-456. 

139 


140  "U'lLLIAM   J.    ^L^YO 

ings  are  unreliable  in  the  early  phases  of  disease,  but  possess  some 
significance  later  in  its  course.  Examination  of  the  blood,  the 
urine,  the  feces,  etc.,  is  of  interest  and  helpful.  The  use  of  the 
gastroscope,  gastrodiaphanoscope,  ar-ray,  etc.,  is  still  experimental. 

The  mechanics  of  the  stomach  is  the  most  interesting  feature 
to  the  surgeon ;  from  this  point  of  view  the  function  of  the  stomach 
is  largely  mechanical.  It  absorbs  fluids,  equalizes  the  temperature 
of  the  ingesta,  and  the  weak  solution  of  hydrochloric  acid  and  pep- 
sin which  is  secreted  breaks  up  the  food-masses,  forming  a  homo- 
geneous material  which  is  fed  down  into  the  small  bowel,  where 
the  real  work  of  digestion  and  absorption  takes  place. 

Any  interference  with  the  outlet  promptly  produces  symptoms 
corresponding  with  the  degree  of  obstruction,  while  ulceration 
or  other  disease  involving  the  wall  of  the  stomach,  preventing  it 
from  acting  as  a  reservoir,  is  also  quickly  resented.  The  distress 
in  each  case  causes  the  patient  to  unconsciously  try  to  adjust  the 
quality  and  quantity  of  food  to  the  loss  of  this  peculiar  function 
of  the  stomach.  The  result  of  obstruction  at  the  pylorus  is  to  in- 
crease the  capacity  of  the  stomach,  and  this  is  often  the  only  ob- 
jective sign  to  which  our  attention  is  called  before  operation.  Di- 
latation is  to  be  expected  in  the  first  group,  of  which  pyloric  stenosis 
is  the  t^'pe,  but  unless  the  disease  of  the  wall  is  sufficiently  near  the 
pylorus  to  add  mechanical  features,  it  is  not  present  in  the  second 
group,  of  which  ulcer  is  the  chief  example. 

Dilatation,  due  to  benign  obstruction  at  the  pylorus,  is  followed 
by  increase  in  the  muscular  wall  of  the  stomach,  the  hypertrophy 
enabhng  the  damaged  organ  to  carry  on  its  function.  This  degree 
of  compensation  is  often  aided  by  the  patient  through  a  selected 
diet.  In  these  cases  compensation,  alternating  with  dilatation  and 
its  discomforts,  gives  a  cHnical  picture  which  may  be  aptly  com- 
pared to  cardiac  insufficiency.  ^Miy  is  it  that  these  patients,  with 
far  greater  symptoms  than  would  be  tolerated  in  either  the  appen- 
diceal or  gall-bladder  regions,  are  allowed  to  go  unrelieved.'  It  is 
not  only  that  we  are  unable  to  know  before  operation  the  exact 
nature  of  the  trouble,  but  that  we  also  distrust  our  ability  to  make 
a  diagnosis  at  the  operating  table. 


I'UOHLKMS    UELATINf;    TO    SUIK.'KUY    OF    STOMAfU  I  1. 1 

In  the  beginning,  every  operation  upon  the  .stomach  partakes 
of  an  exploratory  incision,  and  too  often  the  proposed  operation 
stops  upon  exposure  of  an  extent  of  disease  beyond  intervention. 
This  is  particularly  true  of  cancer.  The  surgical  exploration  of 
the  stomach  may  not  prove  easy.  The  pylorus  and  anterior  wall 
are  open  to  inspection,  and  gross  lesions  of  all  parts  can  be  ascer- 
tained, but  not  so  the  more  minute  forms  of  disease,  such  as  the 
round  ulcer.  Our  plan  has  been  to  explore  by  sight  and  touch  the 
more  accessible  portions  of  the  stomach-wall.  Then,  by  opening 
into  the  lesser  cavity  of  the  peritoneum  through  the  gastrocolic 
omentum,  to  pass  the  hand  behind  the  stomach  and  search  its 
posterior  wall  (Tiffany).  To  explore  the  interior  of  the  gastric 
cavity  a  transverse  incision  is  made  three  inches  in  length  through 
the  anterior  wall  half  way  between  the  pylorus  and  cardiac  orifice. 
Into  this  a  short  rectal  speculum,  two  inches  in  length  and  one  and 
one-half  inches  in  diameter,  is  inserted,  and  the  fluids  removed  by 
suction.  With  the  hand  behind  the  stomach,  nearly  the  whole  of 
its  mucous  surface  can  be  passed  in  review  before  the  end  of  the 
speculum  under  direct  light.  (This  is  a  modification  of  the  method 
first  brought  out  by  Maylard  at  the  International  Congress,  1900.) 

With  a  considerable  lesion  one  may  often  doubt  whether  the 
trouble  is  cancer  or  ulcer;  or,  not  infrequently,  the  seat  of  an  ulcer 
has  undergone  carcinomatous  degeneration,  leading  to  uncertainty. 
This  is  especially  true  of  the  pyloric  region.  We  have  had  two 
cases  in  which  the  thickening  about  a  pyloric  ulcer  was  so  great 
that  even  after  incision,  with  the  parts  open  to  inspection,  we  were 
unable  to  tell  the  difference  macroscopically.  Enlarged  lymphatic 
glands,  unless  distinctly  cancerous,  do  not  help  us.  It  has  been 
our  experience  that  in  the  majority  of  diseases  of  the  stomach 
marked  by  retention  and  fermentation  of  the  food  enlarged  lym- 
phatic glands  are  to  be  found  in  the  omenta.  The  most  common 
forms  of  dilatation  of  the  stomach  are  due  to  the  healing  of  a  gastric 
ulcer  causing  stenosis,  or  to  malignant  disease  involving  the  py- 
lorus. The  only  cases  of  cancer  of  the  stomach  we  have  been  able 
to  diagnosticate  sufficiently  early  to  extirpate  were  the  cases  in 


142  WILLIAM   J.    MAYO 

which  obstruction  and  dilatation  were  present.  Upon  opening 
the  abdomen, this  factor  is  easily  seen  and  needs  no  comment. 

There  is  a  large  group,  however,  of  chronic  cases  of  dilatation  of 
the  stomach  giving  rise  to  symptoms  which,  upon  careful  surgical 
exploration,  show  no  adequate  cause  for  the  condition.  In  other 
cases  hypersecretion  or  hyperchlorhydria  is  the  cause  of  chronic  gas- 
tric distress  in  which  operative  relief  is  indicated.  We  may  say  that 
pyloric  spasm  exists,  due  to  a  microscopic  ulcer.  It  is  a  convenient 
term,  not  capable  of  either  proof  or  refutation.  In  this  connection  I 
have  examined  over  100  stomachs  in  the  course  of  other  operations, 
with  especial  reference  to  the  pylorus.  Under  anesthesia,  if  the 
normal  pyloric  opening  be  compressed  between  the  thumb  and  fin- 
ger, invaginated  into  the  stomach  and  duodenal  walls  on  either  side, 
the  lumen  will  permit  easy  meeting  of  the  opposing  digits,  and  gives 
the  feeling  that  an  opening  exists  about  the  size  of  an  old-fashioned 
silver  three-cent  piece.  Comparing  this  with  the  cases  which  I 
had  previously  diagnosticated  as  having  pyloric  spasm,  little  differ- 
ence could  be  detected.  In  only  four  cases  could  a  definite  thick- 
ening be  demonstrated  in  the  pyloric  ring.  In  these  patients  the 
slight  abnormality  was  situated  posteriorly,  but  in  one  only  did 
incision  reveal  an  ulcer.  It  was  also  noted  that  in  these  four  cases 
there  was  very  little  if  any  dilatation  of  the  stomach. 

In  a  number  of  other  cases  angulation  was  present,  that  is,  a 
high-lying  pylorus  somewhat  firmly  fixed,  with  a  sharp  bend  of  the 
stomach  downward  immediately  proximal  to  it.  In  1896  I  de- 
scribed five  cases  of  this  condition  as  a  cause  of  dilatation  of  the 
stomach,  under  the  title  of  "Valve  Formation."  I  have  seen  a 
number  of  cases  since.  Adhesions  outside  the  lumen  of  the  stom- 
ach, the  result  of  a  perigastritis  from  gastric  ulcer  or  a  cholecystitis, 
may  be  the  cause.  (Robson,  Cabot,  and  others  have  described  a 
number  of  such  cases.)  We  have  met  with  this  condition  most 
frequently  in  connection  with  work  on  the  biliary  tract.  In  some 
cases,  however,  when  no  apparent  cause  for  the  dilatation  exists, 
the  stomach-wall  is  hypertrophied,  and  for  this  reason  we  must  con- 
clude that  in  some  manner  obstruction  does  exist. 

The  most  perplexing  cases  are  those  of  neurotic  origin,  in  which 


Fig.  8  — Traction  weight  of  small  bowel,  producing  funnel  shape  of  stomach  at  site  of  anastomosis. 


Fig.  9. — Showing  proper  and  improper  locations  of  opening:    a.  Proper  position,  leaving  no  pouch; 

b,  usual  position,  forming  intragastric  pouch. 


I'HOJiLKMS    UKLATING    TO    SLUCiKUY    OF    STOMACH  \  V.i 

class  I  would  i)l;ice  the  various  grades  of  gaslroj)tosis.  Some  of 
these  invalidji  have  also  an  accompanying  dilatation,  but  usually 
of  the  atonic  variety,  that  is,  without  increased  muscular  thicken- 
ing of  the  wall.  On  surgical  exploration  such  a  stomach  is  usually 
found  to  be  empty  and  contracted,  although  j)revious  examination 
has  siiown  it  to  be  dilated.  In  tlie  purely  neurotic  variety,  while 
there  may  be  little  or  no  change  in  the  size  or  position  of  the  stom- 
ach, symptoms  of  ulcer  may  be  so  perfectly  simulated  as  to  lead  to  an 
exploration  which  proves  negative.  On  manipulating  such  a  stom- 
ach it  nuiy  contract  in  small  areas,  and  for  a  moment  look  as  though 
an  ulcer  existed,  to  as  suddenly  disappear,  or  the  whole  stomach  may 
undergo  vermicular  contraction  until  it  is  no  larger  than  the  colon. 
In  two  such  instances  I  have  seen  the  pylorus  suddenly  dilate  until 
two  or  more  fingers  could  be  invaginated  through  it.  These  cases 
must  be  classified  surgically  with  movable  kidney,  movable  retro- 
version of  the  uterus,  varicocele,  etc.,  usually  occurring  in  neu- 
rasthenic individuals,  and  occasionally  demanding  an  operation, 
which  may  be  followed  by  benefit.  I  have  examined  a  number  of 
such  stomachs,  and  we  have  operated  upon  a  few,  in  wdiich  dilata- 
tion coexisted  or  a  mistake  in  diagnosis  w'as  made.  One  has  a 
feeling  that  we  should  reject,  surgically,  this  whole  group,  yet  even 
neurasthenics  are  not  exempt  from  actual  disease,  although  we 
naturally  subject  them  to  a  most  careful  and  painstaking  prelim- 
inary examination  in  which  subjective  symptoms  are  accorded  but 
little  weight.  Speaking  from  an  operative  standpoint,  dilatation 
with  retardation  of  the  passage  of  the  food  out  of  the  stomach  is 
the  most  important  surgical  indication.  When  does  this  condition 
demand  an  operation?  It  is  largely  a  personal  equation  between 
the  experience  of  the  surgeon  and  the  disability  of  the  patient. 
The  value  of  gastric  drainage  in  these  cases  is  apparent  and  needs 
no  argument.  The  desirability  of  drainage  of  the  non-dilated 
stomach  is  based  largely  upon  clinical  observation.  Theoretically, 
it  would  not  strike  one  that  a  well-drained  or  contracted  stomach, 
even  if  ulcer  be  present,  would  be  benefited  by  such  a  procedure. 
It  is  claimed  that  gastric  drainage,  especially  gastro-enterostomy, 
rests  the  stomach,  permits  escape  of  secretions,  and  increases  the 


144  WILLIAM   J.    ?HAYO 

nutrition,  thereby  aiding  recovery.  Our  own  experience,  while 
Hmited,  in  a  general  way  seems  to  bear  out  this  conclusion,  but 
not  wholly  so.  If  we  divide  our  cases  of  ulcer  into  two  groups,  in 
the  first  place  all  the  cases  in  which  ulcer  existed  in  the  pyloric  end 
of  the  stomach,  and  in  which  the  capacity  of  the  stomach  was  in- 
creased from  any  cause,  and  in  the  second  group  place  all  the  cases 
in  which  the  contrary  existed,  we  find  the  results  much  less  favor- 
able in  the  latter.  In  cases  of  ulcer  in  the  small  stomach  excision 
offers  a  more  satisfactory  means  of  cure,  although  I  regret  to  say 
we  have  had  but  two  cases  in  which  we  were  able  to  do  this. 

Gastric  drainage  can  be  best  established  in  two  ways :  (1)  Pyloro- 
plasty, and  (2)  gastro-enterostomy.  Pyloroplasty,  after  the  method 
of  Heineke-Mikulicz,  has  been  made  fifteen  times  in  St.  Mary's  Hos- 
pital; in  four  of  these  cases  failure  permanently  to  relieve  the  symp- 
toms necessitated  a  secondary  gastro-enterostomy:  the  stomach  was 
greatly  dilated,  and,  by  a  more  rapid  stretching  of  its  greater  curva- 
ture, also  pouched.  The  plastic  operation  on  the  pylorus  in  each  in- 
stance was  found  to  have  been  successful  so  far  as  enlarging  its  cali- 
ber was  concerned,  but  the  degenerated  muscle-fiber  of  the  stomach- 
wall  had  been  unable  to  elevate  the  food  from  the  gastric  pouch  to 
the  high-lying  pylorus,  and  the  symptoms  were  largely  unabated. 
As  at  the  secondary  operation  the  pylorus  was  always  found 
adherent,  it  occurred  to  me  that  perhaps  after  the  plastic  opera- 
tion, if  the  pylorus  could  be  anchored  down  in  the  vicinity  of  the 
umbilicus  and  allowed  to  become  adherent  at  that  point,  it  would 
drain  the  stomach  better.  We  have  practised  this  in  five  cases, 
but  as  we  have  also  been  more  careful  in  the  selection  of  non- 
pouched  stomachs  for  the  operation,  I  am  uncertain  whether  the 
better  results  have  been  due  to  the  method  or  to  the  care  in  selec- 
tion :  There  were  no  deaths  in  this  group  of  cases  and  no  later  com- 
plications. Pyloroplasty  will  have  a  limited  field  of  usefulness  in 
cases  in  which  dilatation  of  the  stomach  is  not  great.  If  it  can  be 
shown  that  the  pyloric  spasm  is  a  large  factor  in  the  clinical  course 
of  gastric  ulcer,  pyloroplasty,  which  destroys  the  sphincter  action 
of  the  muscle,  might  be  the  operation  of  choice  in  the  group  of  cases 
without  dilatation,  or  in  which  the  stomach  is  contracted,  as  it  is 


PROBLEMS  RELATING  TO  SURGERY  OF  STOMACH       145 

in  these  cases  that  gastro-enterostomy  has  been  the  least  beneficial 
and  late  complications  have  occasionally  arisen. 

All  in  all,  we  have  found  gastro-enterostomy  to  be  the  most 
satisfactory  operation  on  the  stomach.  This  operation  was  per- 
formed 80  times,  with  8  deaths.  For  cancer,  21  gastro-enteros- 
tomies  with  4  deaths,  the  greatest  length  of  life  was  nineteen  months, 
with  ability  to  carry  on  manual  labor  for  more  than  sixteen  months. 
With  few  exceptions,  however,  the  palliation  has  been  of  such  short 
duration  as  liardly  to  justify  the  operation.  The  hope  of  the 
future  for  cancer  of  the  stomach  is  early  exploration  and  extirpa- 
tion. 

For  benign  conditions,  gastro-enterostomy  has  the  great  ad- 
vantage in  that  it  drains  the  stomach  from  the  lowest  point,  re- 
lieving the  retention  of  obstruction  equally  with  the  painful  con- 
tact which  the  food  causes  in  gastric  ulcer.  Twelve  cases  of  chronic 
intractable  ulceration  in  the  vicinity  of  the  pylorus,  in  which  some 
narrowing  of  the  orifice  was  produced  and  dilatation  was  present, 
were  benefited,  the  cure  in  the  11  that  recovered  from  the  operation 
being  fairly  good.  In  6  cases  of  ulcer  in  which  the  pylorus  was  of 
normal  size  and  the  stomach  contracted,  relief  was  less  certain  and 
slow  to  come  about.  In  3  cases  of  ulcer  subjected  to  gastro-enter- 
ostomy a  secondary  operation  became  necessary  for  angulation 
at  the  site  of  the  anastomosis.  This  took  place  after  some  weeks 
or  months,  and  was  found  to  be  due  to  a  contraction  which  fol- 
lowed at  the  anastomotic  opening.  This  subsequent  narrowing  is 
of  no  consequence  so  far  as  the  stomach  is  concerned,  but  as  one- 
third  the  lumen  of  the  small  bowel  is  involved,  the  reduction  may 
be  a  serious  matter,  causing  an  angulation  later.  The  attempt  at 
obliteration  comes  on  after  the  stomach  has  resumed  its  function, 
and  takes  place  only  in  the  cases  in  which  the  pylorus  was  unob- 
structed, nature  making  the  usual  endeavor  to  close  an  unnecessary 
fistula.  The  symptoms  of  this  complication  are  attacks  of  burn- 
ing pain  in  the  stomach,  with  nausea,  and  perhaps  a  little  bile- 
stained  fluid  may  be  regurgitated,  or  at  times  be  washed  out  of  the 
stomach,  but  there  is  usually  no  stagnation  or  vomiting  of  food. 
Entero-anastomosis  relieves  the  condition.     It  would  seem  wise 

VOL.  I — 10 


146  WILLIAM   J.    MAYO 

to  make  an  entero-anastomosis  at  the  primary  operation  whenever 
gastro-enterostomy  is  performed  in  a  case  in  which  the  pylorus  is 
unobstructed.  In  no  case  of  permanently  obstructed  pylorus  has 
contraction  of  the  anastomotic  opening  followed  in  our  cases,  so 
far  as  we  know.  We  have  never  seen  the  opening  completely 
closed. 

The  splendid  drainage  established  in  the  dilated  stomach,  which 
presupposes  some  interference  with  the  passage  of  the  food,  leads  us 
to  use  gastro-enterostomy  for  temporary  purposes  in  a  normally 
drained  stomach.  Even  in  these  cases  it  cures  many  and  relieves  the 
majority.  As  to  the  method  of  performing  gastro-enterostomy,  there 
are  still  a  few  questions  to  be  settled:  (1)  Shall  we  use  the  suture  or 
the  Murphy  button?  So  far  as  I  can  judge,  the  results  are  about  the 
same.  (2)  Shall  it  be  on  the  anterior  or  posterior  wall  of  the  stom- 
ach .f^  Here  again  there  is  little  choice.  We  have  made  69  an- 
terior and  11  posterior,  with  equally  good  results.  Theoretically, 
the  posterior  operation  would  seem  the  better,  as  one  can  secure 
the  jejunum  at  a  higher  point.  We  have  made  the  posterior  within 
6  inches  of  the  origin  of  the  jejunum,  and  it  takes  14  inches  to 
form  a  loop  for  the  anterior  method.  Making  the  posterior  opera- 
tion so  close  is  not  a  safe  procedure,  since,  should  it  become  neces- 
sary to  do  an  entero-anastomosis  later,  there  is  not  sufficient  room 
on  the  proximal  side  of  the  anastomotic  opening  for  this  purpose. 
We  lost  one  case  from  this  cause.  In  either  operation,  from  14  to 
16  inches  of  intestine  should  be  left  on  the  proximal  side. 

The  main  thing  in  gastro-enterostomy  is  that  the  opening  should 
be  low  down,  near  the  greater  curvature,  in  either  operation.  We 
have  had  little  trouble  with  primary  pernicious  vomiting  (vicious 
circle)  for  more  than  four  years  since  we  began  this  practice.  The 
anterior  operation  is  usually  made  about  half-way  between  the 
lesser  and  greater  curvatures,  and  where  there  are  but  few  blood- 
vessels. This  is  a  bad  practice,  since  it  leaves  a  pouch  into  which 
the  bile  and  pancreatic  secretions  can  easily  enter,  and  it  encourages 
vicious  circle.  In  doing  the  posterior  operation  the  inferior  border 
is  more  accessible,  and  one  naturally  places  the  opening  lower  down. 
The  anastomosis  should  be  effected  in  such  manner  that  its  inferior 


Fig.  to.  — lorminj;  an  apron  of  the  omentum,  attachinf:  to  thf  ~toniacn  arM)\c  inc  anailomosis. 


PROBLEMS  RELATING  TO  SURGERY  OF  STOMACH      147 

edge  shall  be  at  the  bottom  of  the  stomach  pouch,  on  a  line  with 
the  greater  curvature  in  either  the  anterior  or  posterior  operation 
(Fig.  9). 

In  two  of  our  cases  of  gastro-enterostomy  the  bowel  detached 
spontaneously  from  the  stomach, — once  on  the  seventh  and  once 
on  the  tenth  day, — with  resultant  leakage  and  death,  contrary  to 
Chlumsky's  experiments,  in  which  it  was  shown  that  union  was  firm 
after  the  fifth  day.  It  was  noted  at  the  autopsy  that  it  was  the 
superior  edge  of  the  union  only  that  detached;  the  lower  edge, 
being  just  at  the  origin  of  the  gastrocolic  omentum,  was  so  pro- 
tected as  to  be  of  unusual  strength.  After  making  the  anterior 
inferior  anastomosis  we  grasp  the  omentum  upon  either  side  and 
pull  it  upward  in  such  a  manner  as  will  not  tract  upon  the  transverse 
colon.  The  two  upper  free  ends  are  fastened  together  and  then  to 
the  stomach-wall,  not  less  than  one  inch  above  the  anastomosis, 
with  fine  catgut.  The  edges  of  the  omentum  are  then  united  to 
each  other  for  two  and  one-half  inches,  forming  an  apron  which 
completely  covers  the  site  of  union,  protecting  the  weak  point,  yet 
having  no  connection  with  it  (Fig.  10).  Should  the  omentum  drag 
in  the  future,  the  strain  would  come  above  the  opening  upon  the 
stomach  and  increase  that  funnel  shape  (Fig.  8)  which  the  stomach 
should  assume  after  the  operation  is  properly  completed.  In  the 
posterior  inferior  operation  a  few  sutures  attaching  the  margins  of 
the  torn  mesentery  of  the  transverse  colon  to  the  stomach  will 
furnish  the  same  protection  to  the  union.  Gastro-enterostomy  for 
late  cancer  of  the  pylorus  will  be  followed  by  bad  results  without 
regard  to  method,  and  if  ascites  be  present,  union  will  probably 
not  take  place. 


COMPLICATIONS     FOLLOWING    GASTRO- 
ENTEROSTOMY* 

WILLIAM    J.    MAYO 


During  the  past  ten  years  98  gastro-enterostomies  have  been 
performed  in  St.  Mary's  Hospital,  with  9  deaths.  The  mortaUty 
in  the  malignant  cases  was  20  per  cent.,  and  in  the  benign  cases, 
6  per  cent.  During  this  time  14  pylorectomies  and  partial  gas- 
trectomies have  been  made,  with  2  deaths — 14  per  cent.  Of 
these,  9  were  excisions  with  complete  closure  of  both  the  stomach 
and  duodenal  ends,  communication  being  established  by  means 
of  an  independent  gastrojejunostomy  of  the  usual  type.  One 
death. 

These  9  cases,  added  to  the  98  cases  above  mentioned,  give 
107  gastro-enterostomies  with  10  deaths — an  average  mortality 
of  9  per  cent.  The  causes  of  death  were  as  follows:  Exhaustion, 
3  cases ;  exhaustion  in  which  pernicious  vomiting  was  a  prominent 
feature,  2  cases;  progressive  pneumonia,  3  cases;  detachment  of 
the  anastomosed  intestine  from  the  stomach- wall,  2  cases.  The 
deaths  from  exhaustion  were  the  result  of  starvation  at  the  time 
of  the  operation.  The  patients  appeared  fairly  well  until  the 
fourth  to  seventh  day,  when  a  gradual  failure  of  the  vital  forces 
appeared  and  death  ensued  in  from  twelve  to  twenty-four  hours. 
The  postmortem  showed  the  abdominal  condition  to  be  good. 
Cachectic  subjects  bear  rectal  feeding  badly,  and  giving  nourish- 
ment by  the  stomach  should  be  practised  early,  when  possible. 

The  two  cases  in  which  regurgitant  vomiting  hastened  death 
were  among  the  early  operations,  in  which  the  intestine  was 
joined  to  the  anterior  wall  of  the  stomach  halfway  between  the 

*  Reprinted  from  "Annals  of  Surgery,"  August,  1902. 
148 


Fig.  II. — Showing  proper  and  improper  locations  of  opening:    a.  Proper  position,  leaving  no  pouch 
b,  usual  position,  forming  intragastric  pouch. 


COMPLICATIONS    FOLLOWING   GASTRO-ENTEROSTOMY  149 

greater  and  lesser  curvatures,  causing  an  intragastric  pouch  to 
form,  which  •  contrihulcd  to  tlie  unfortunate  conii)lication.  In 
neither  case  could  it  be  said  that  the  vomiting  itself  caused 
death,  but  in  the  feeble  condition  of  the  patients  it  certainly  was 
a  factor. 

It  will  be  noted  that  nearly  one-third  of  the  total  death-rate 
was  due  to  bronchopneumonia. 

There  have  been  many  explanations  as  to  the  frequency  with 
which  lung  complications  occur  following  operations  upon  the 
stomach.  These  complications  were  believed  to  be  the  result  of 
general  anesthesia,  but  experience  has  shown  that  they  are  rela- 
tively as  frequent  after  the  use  of  a  local  anesthetic.  The  situation 
of  the  incision  in  the  epigastrium,  preventing  coughing  and  ex- 
pectoration, is  thought  to  be  an  element  in  causation,  yet  similar 
incisions  in  the  gall-bladder  region  have  no  such  effect.  The 
latest  hypothesis  is  that  some  of  the  venous  blood  returning  from 
the  stomach  does  not  pass  through  the  portal  vein,  and  in  this 
way  infected  emboli  are  carried  directly  into  the  circulation  and 
pass  at  once  to  the  lungs.  In  two  of  the  three  cases  a  chronic 
bronchial  cough  was  present  at  the  time  of  operation,  and  the 
patients  were  in  bad  general  condition.  In  one  case  material 
was  aspirated  through  the  trachea  from  the  esophagus,  causing 
pneumonia.  It  is  difficult,  by  means  of  the  stomach-tube, 
thoroughly  to  cleanse  and  empty  the  greatly  dilated  stomach 
in  debilitated  subjects.  In  this  case,  on  elevating  the  stomach 
out  of  the  abdominal  incision,  some  of  the  jQuid  contents  gravi- 
tated into  the  esophagus.  This  should  be  avoided  by  elevation 
of  the  head  and  thorax  at  this  time.  The  recumbent  posture  fol- 
lowing operation  is  apparently  injurious  in  some  cases,  and  we 
now  encourage  the  old  and  feeble  to  sit  up  early.  It  is  evident 
that  there  is  as  yet  no  entirely  adequate  explanation  for  the  pro- 
duction of  the  pulmonary  complication.  There  are  probably 
several  contributing  causes  in  most  cases. 

In  the  two  cases  in  which  the  anastomosed  intestine  was 
detached,  causing  death  from  leakage,  one  took  place  on  the 
seventh    day    after    gastro-enterostomy    for    malignant    pyloric 


150  WILLLIM   J.    MAYO 

obstruction.  There  was  a  small  amount  of  free  fluid  present 
in  the  abdomen  at  the  time  of  operation,  which  would  usually 
contraindicate  a  plastic  procedure,  such  as  gastro-enterostomy. 
In  the  second  case,  detachment  on  the  ninth  day  followed  an 
epileptic  seizure.  This  was  in  a  patient  with  benign  obstruction, 
who  had  up  to  that  time  done  unusually  well.  He  had  suffered 
from  epilepsy  for  years,  and  the  aura  began  in  the  epigastric 
region.  In  a  violent  contraction  of  the  stomach  such  a  detach- 
ment might  easily  take  place.  Chlumsky's  experiments  on  pre- 
sumably healthy  animals  went  to  show  that  after  five  days  the 
union  was  perfect.  That  this  is  not  true  in  diseased  states  in  the 
human  subject  is  shown  by  these  two  cases. 

Of  the  97  cases  which  recovered  from  the  operation,  5  benign 
cases  came  to  secondary  operation  on  account  of  changes  at  the 
anastomotic  orifice. 

The  most  important  feature  in  the  mechanics  of  the  anasto- 
mosis is  that  the  union  shall  be  at  the  inferior  border  of  the 
stomach,  close  to  the  greater  curvature,  and  at  the  bottom  of 
the  gastric  pouch,  giving  a  funnel  shape.  Properly  placed,  the 
anastomotic  opening  should  have  its  inferior  border  at  the  bottom 
of  the  stomach,  and  as  to  whether  the  opening  shall  extend  from 
this  point  upward  anteriorly  or  posteriorly  is  really  of  little  mo- 
ment. (See  Fig.  11.)  The  anterior  operation  has  usually  been 
placed  relatively  higher  than  the  posterior,  to  avoid  the  blood- 
vessels, causing  an  intragastric  pouch  to  form,  which  has  been 
one  source  of  pernicious  vomiting.  The  posterior  operation,  for 
technical  reasons  (easier  exposure),  is  usually  placed  nearer  the 
greater  curvature.  The  union  in  the  107  cases  under  discussion 
was  made  to  the  anterior  wall  of  the  stomach  8.3  times,  and  24 
times  to  the  posterior  wall,  with  equally  good  results,  so  that 
location  of  the  opening  on  the  anterior  or  posterior  wall  cannot 
of  itself  be  essential.  In  our  experience  one  operation  is  as  easy 
as  the  other.  For  thin  subjects  with  a  long  mesocolon  we  prefer 
the  posterior  method.  If  the  mesentery  is  short  or  contains  much 
fat,  or  if  the  vascular  loop,  from  the  superior  mesenteric  artery, 
which  supplies  the  transverse  colon,  is  small,  bringing  the  opening 


CO.Ml'LKATIONS    !•  OIJ-*  )\VI  Nf ;    (;A.STKO-IAr  I  .UOSTO.M  V  1.51 

in  the  poslerior  layer  of  tlic  j^'aslroeolir  ornciitMrn  iti  rlose  prox- 
imity to  it,  the  aiiU'rior  operation  is  preferre*!.  After  i)0.stcrior 
gastro-enterostomy  the  torn  edj^es  of  the  mesentery  are  sutured 
to  the  posterior  wall  of  the  stomach,  as  advised  l)y  Willy  Meyer, 
to  prevent  downward  displacement  and  interference  with  the  loop, 
as  hapi)enc(l  to  Meyer,  Czerny,  Korte,  and  others.  These  sutures 
arc  introduced  in  such  a  manner  as  to  provide  a  short  flap  of  the 
mesenteric  marf:^in,  which  drops  over  the  anastomotic  opening, 
furnishing  further  i)rotcction.  After  the  anterior  operation,  the 
edges  of  the  omentum  are  caught  each  side  of  the  anastomosis 
and  sutured  to  each  other  and  to  the  stomach-wall  one  inch  ahove 
the  opening.  The  edges  are  united  to  each  other  downward  for 
three  inches,  forming  an  apron  over  the  anastomosis,  yet  having 
no  connection  with  it;  and  as  this  is  done  with  a  fine  catgut  suture, 
the  adhesion  is  not  of  itself  permanent.  This  makes  the  omentum 
available  if  leakage  occurs,  and  in  time  the  omentum  returns  to 
its  normal  situation  if  no  accident  happens.  This  may  seem  an 
unnecessary  precaution,  but  when  it  is  considered  that  20  per 
cent,  of  the  deaths  were  due  to  se])aration  of  the  bowel  from  the 
stomach  at  a  time  (ninth  and  tenth  day)  when  neither  suture  nor 
button  would  furnish  adequate  support,  it  is  not  unreasonable. 
Both  of  our  fatal  cases  followed  anterior  operations,  and  it  was 
the  superior  edge  of  the  union  which  gave  way,  as  shown  by  post- 
mortem. The  inferior  margin,  being  protected  by  the  origin  of 
the  omentum,  was  exceedingly  firm.  We  have  used  the  Murphy 
button  in  all,  except  one  of  our  cases,  in  which  the  suture  and  the 
Robson  bone  bobbin  were  employed  to  meet  a  special  indication. 

Case  I. — Gastro-enterostomy;  Reoperation  Four  Years  Later 
for  Secondary  Ulceration;  Recovery. — Mrs.  H.  H.  O.,  aged  thirty- 
eight  years,  Scandinavian,  mother  of  three  children,  housewife, 
was  admitted  to  St.  Mary's  Hospital  May,  1899,  with  the  follow- 
ing history:  Has  had  symptoms  of  ulceration  of  the  stomach  for 
several  years ;  for  the  j)ast  two  years  the  trouble  has  been  constant. 
The  vomiting,  which  at  first  occurred  immediately  after  taking 
food,  is  now  delayed  a  number  of  hours,  but  the  larger  part  of  the 
nourishment  is  eventually  rejected.     She  eats  as  small  an  amount 


152  WILLIAM  J.   MAYO 

as  possible  and  is  limited  entirely  to  liquid  food.  Has  lost  35 
pounds  or  more  in  weight.     Personal  and  family  history  good. 

Physical  Examination. — Emaciation  marked;  skin  dry;  pulse 
and  temperature  normal.  Upper  abdominal  region  distended. 
On  inspection,  peristaltic  waves  can  be  seen  passing  from  left  to 
right.  Splashing  phenomenon  easily  developed.  On  air  disten- 
tion the  greater  curvature  of  the  stomach  found  to  lie  on  a  line 
with  the  crest  of  the  ilium.  Test-meal  shows  free  acid.  Diagno- 
sis, benign  pyloric  obstruction  due  to  the  cicatrization  of  an  ulcer. 

Operation. — Irregular  cicatrix  involving  pylorus,  three-fourths 
of  an  inch  in  diameter  and  one  and  one-fourth  inches  in  length. 
Anterior  gastro-enterostomy.  Recovery  uneventful.  For  three 
years  she  remained  in  splendid  health,  gaining  over  40  pounds  in 
weight.  April  1,  1902,  was  readmitted  to  hospital  on  account 
of  return  of  previous  symptoms  of  obstruction,  which  had  begun 
suddenly  three  months  before,  and  were  supposed  to  be  due  to 
an  attack  of  appendicitis.  Patient  had  lost  much  flesh  and  was 
on  a  liquid  diet.  The  trouble  was  evidently  due  to  some  inter- 
ference with  the  outlet  of  the  stomach. 

Ojperation  kpxW  2,  1902:  Amass  of  adhesions  was  encountered 
to  the  right  of  the  median  line,  due  to  an  ulcer  of  the  stomach  just 
above  the  anastomotic  orifice,  and  involving  the  opening  above 
and  upon  the  right  side. 

Perforation  had  occurred  and  the  adhesion  to  the  abdominal 
wall  had  prevented  leakage.  The  transverse  colon  was  closely 
adherent  and  much  reduced  in  caliber  where  it  passed  under  the 
anastomosis.  The  entire  ulcerated  area  was  excised,  leaving  a 
large  opening  with  only  one-fourth  of  the  gastro-intestinal  union 
on  the  left  side  intact.  This  defect  was  sutured,  and  the  gastro- 
enterostomy completed  by  suture  over  a^Robson  bone  bobbin, 
the  large  plastic  being  protected  by  the  omentum.  The  Murphy 
button  was  found  in  the  stomach  somewhat  corroded,  but  in  fairly 
workable  condition.  Pylorus  completely  obstructed.  The  stom- 
ach was  dra'VNTi  down  into  a  funnel  at  the  site  of  the  anastomosis. 
I  am  under  the  impression  that  at  the  time  of  the  sudden  symp- 
toms the  button  became  impacted  and  caused  the  ulceration.  This 
is  surmise,  as  it  was  found  in  the  fundus  of  the  stomach. 

If  the  stomach-wall  is  thick,  the  muscular  and  peritoneal 
coats  should  be  incised  before  the  suture  is  placed,  and  the  suture 
should  grasp  only  a  small  portion  of  these  structures,  otherwise 
the  button  may  be  held  in  position  too  long.     In  many  cases  in 


COMPLK'ATIOX.S    FOI-LOWIXG    GASTRO-EXTEROSTOMY  153 

which  the  button  passes,  vomiting,  with  symptoms  of  obstruction, 
may  appear  in  the  second  or  third  week  while  it  is  in  transit. 
Gastric  lavage  and  rectal  feeding  for  a  day  or  two  will  cause  these 
symptoms  to  subside. 

The  suture  oi)eration  for  gastro-enterostomy  is  undoubtedly 
just  as  good  as  the  button,  and,  so  far  as  can  be  judged,  the  results 
are  about  the  same.  Among  men  of  great  experience  Kocher  uses 
the  suture  and  the  posterior  method;  Czerny,  the  button  and  the 
posterior;  Mikulicz  prefers  the  suture  in  benign  cases  and  the 
button  in  malignant  cases,  and  uses  the  anterior  operation  alto- 
gether. He  finds  that  an  entero-anastomosis  is  necessary  in  the 
suture  operation  to  prevent  pernicious  vomiting,  but  does  not 
find  it  necessary  with  the  button,  which  tends  to  prevent  angula- 
tion while  in  sitii,  and  this  is  during  the  dangerous  period.  Rob- 
son's  bone  bobbin  acts  in  a  similar  manner.  Kelling  found  that 
with  the  suture  a  ring  of  mucous  membrane  projected  into  the 
stomach,  diminishing  the  caliber  of  the  opening.  The  opening 
is  less  perfect  with  the  suture,  and  entero-anastomosis  is  more 
often  necessary  to  prevent  pernicious  vomiting.  These  advan- 
tages in  favor  of  the  button  are  counterbalanced  by  its  tendency 
to  drop  into  the  stomach  and  remain  there  (Case  I).  This  usually 
does  no  harm,  and  in  malignant  disease,  at  least,  does  not  counter- 
balance the  advantage. 

In  our  earlier  experience  with  gastro-enterostomy,  the  ope- 
ration was  performed  entirely  for  pyloric  obstruction,  and  in  but 
two  cases  (IV  and  V)  did  any  secondary  complication  develop 
with  regard  to  the  orifice,  except  its  occasional  occlusion  by  an 
advancing  malignant  growth.  Two  cases  of  malignant  obstruc- 
tion, examined  postmortem  after  the  lapse  of  some  months,  showed 
no  marked  contraction  of  the  opening.  For  non-malignant 
pyloric  obstruction  patients  in  the  best  of  health,  all  the  way  from 
the  present  time  up  to  eight  years  after  the  operation,  demonstrate 
the  permanence  of  the  artificial  opening.  In  two  benign  cases 
dying  of  other  causes  six  months  and  three  years  respectively  after 
the  operation,  and  representing  an  anterior  and  a  posterior  location 
of  opening,  there  was  no  contraction.     In  a  case  reported  by 


154  WILLIAM   J.    MAYO 

Cordier  after  six  and  one-half  years  death  from  other  cause  allowed 
a  postmortem  examination,  and  there  was  no  contraction  of  the 
anastomotic  opening  found.  Without  going  into  detail,  it  may- 
be said  that  if  permanent  obstruction  at  the  pylorus  exists,  no 
marked  contraction  of  a  properly  formed  gastro-enterostomy  may 
be  feared,  unless  by  accident  (Case  V). 

About  three  years  ago  gastro-enterostomy  for  the  relief  of 
ulcer  was  first  performed  at  St.  Mary's  Hospital,  and  since  that 
time  with  increasing  frequency — about  25  cases  in  all.  In  a  ma- 
jority of  these  cases  the  pylorus  was  not  mechanically  obstructed, 
although  the  ulcer  was  usually  in  the  pyloric  region,  and  in 
some  cases  ultimate  cicatrization  might  be  expected  materially 
to  reduce  the  caliber  of  the  normal  opening.  In  three  of  these 
cases  angulation  and  obstruction  at  the  site  of  the  anastomosis 
occurred  at  a  later  date  (Cases  II,  III,  and  IV).  In  these  cases 
secondary  exploration  revealed  a  marked  contraction  of  the  orifice, 
reducing  its  size  to  that  of  a  lead-pencil  or  less,  although  in  no 
case  was  obliteration  complete.  There  was  found  an  angulation 
of  the  jejunum  at  the  attachment,  causing  a  spur  which  accounted 
for  the  symptoms.  The  reduction,  so  far  as  the  stomach  was 
concerned,  was  of  little  moment,  but  a  contraction  involving 
one-third  of  the  lumen  of  the  small  bowel  was  serious  and  caused 
valve  formation. 

Case  II. — Entero-anastomosis  Thirteen  Months  After  Gastro- 
enterostomy; Recovery. — Miss  G.  C,  aged  twenty-one  years, 
American,  seamstress,  was  admitted  to  St.  Mary's  Hospital  May 
9,  1900,  with  a  typical  history  of  ulcer,  which  had  existed  for  more 
than  a  year  and  defied  ordinary  methods  of  treatment.  Hemat- 
emesis  had  been  a  prominent  feature,  and  on  two  occasions  was 
so  copious  as  to  threaten  life;  she  had  lost  25  pounds  in  weight. 
Family  and  personal  history  otherwise  good. 

Physical  Examination. — Marked  anemia  from  the  hemor- 
rhages; organs  other  than  stomach  normal.  A  painful  point  the 
size  of  a  silver  dollar  in  the  epigastrium.  Stomach-contents  not 
examined,  it  being  feared  that  the  necessary  manipulation  might 
cause  a  return  of  the  hemorrhage. 

May    10th,    anterior    gastrojejunostomy;     Murphy    button. 


COMPLKATIONS    lOIJ.OWIXG    f;ASTUO-i:.\TKKr).ST(>.M V  \~)') 

Stomach  small,  ijyloriis  miobstructed,  ulceration  on  lesser  cur- 
vature of  irrcf^ular  outline,  an  inch  in  diameter,  shown  hy  indura- 
tion, and  covered  hy  i)erijj;aslric  adhesions.  JJulton  passed  duriiif^ 
third  week.  Dischar^'cd  in  the  fourth  week.  Rapid  gain  in 
weight  and  complete  disappearance  of  symptoms  for  four  months. 
She  then  began  to  have  attacks  of  burning  pain  in  the  stomach; 
tiiese  became  more  fref[uent,  and  occasionally  a  little  bile-stained 
fluid  would  be  vomited.     Xo  great  loss  of  weight  or  strength. 

In  June,  1901,  exploration  revealed  the  fact  that  the  gastro- 
intestinal fistula  had  contracted  to  the  size  of  a  lead-pencil  or 
smaller;  this  produced  a  kink  of  the  jejunum  at  the  site  of  the 
anastomosis.  Entero-anastomosis  between  the  afferent  and  effer- 
ent limbs  of  the  jejunum  promptly  relieved  the  symptoms.  Patient 
now  in  good  health. 

Case  III. — Secondary  Gastro-enterostomy  and  Entero-anasto- 
mosis Twenty  Days  after  Primary  Gastro-enterostomy ;  Recovery. — 
P.  D.,  male,  aged  thirty  years,  German,  farmer,  was  admitted  to 
St.  Mary's  Hospital  March  21,  1901.  History  of  chronic  ulcer 
of  the  stomach  extending  over  six  years,  which  had  obstinately 
resisted  treatment.  During  most  of  this  time  he  had  been  inca- 
pacitated for  labor.  To  relieve  the  pain,  semi-starvation  had  been 
practised.     Personal  and  family  history  negative. 

Physical  Examination. — An  emaciated  man  of  sallow  com- 
plexion, dry  and  leathery  skin.  Heart,  lungs,  kidneys,  etc.,  in 
normal  condition.  Tenderness  just  above  umbilicus.  Stomach 
moderately  dilated;    free  acid  and  some  retardation  of  food. 

Operation  March  2'-2d:  Anterior  gastrojejunostomy;  Murphy 
button.  Ulcer  on  posterior  wall  and  adherent  to  pancreas.  The 
latter  enlarged  and  thickened;  no  mechanical  obstruction  at  the 
pylorus.  For  two  weeks  patient  did  very  well,  then  began  to 
vomit  biliary  and  pancreatic  secretions;  button  passed  on  six- 
teenth day.  Vomiting  at  first  intermittent,  and  no  food  returned 
unless  given  during  the  period  of  active  regurgitation.  Twenty 
days  after  the  primary  operation  the  abdomen  was  reopened. 
The  anastomotic  opening  had  contracted  to  the  size  of  a  lead- 
pencil,  and  spur  formation  of  the  small  bowel  was  marked.  As  it 
seemed  improbable  that  the  ulcer  should  have  permanently  cica- 
trized in  this  short  space  of  time,  anterior  gastrojejunostomy  was 
again  ]>erformed  with  the  Murj)hy  button,  and  an  entero-anas- 
tomosis short  circuiting  the  l)iliary  and  pancreatic  secretions 
below  both  openings  was  made  by  means  of  a  small  button. 


156  WILLIAM   J.    IVIAYO 

Discharged  in  three  weeks.  The  patient  rapidly  gained  in  weight 
and  strength.  He  is  now  in  good  health  and  able  to  perform 
manual  labor. 


Entero-anastomosis  promptly  relieved  the  condition  in  these 
two  cases.  In  the  third,  for  reasons  referred  to  later,  death 
ensued.  Contraction  of  the  anastomotic  opening  is  to  be  expected 
if  the  pylorus  is  unobstructed;  but  that  it  does  not  always  pro- 
duce symptoms  was  shown  in  a  fourth  case,  in  which  gastro- 
enterostomy for  an  active  ulcer  had  promptly  relieved  a  most 
serious  condition.  At  a  secondary  operation  for  a  pelvic  tumor, 
some  months  later,  a  great  contraction  of  the  orifice  was  found, 
but  without  unpleasant  symptoms  arising  therefrom.  In  Case  V, 
after  the  first  entero-anastomosis  failed  to  relieve,  the  writer  was 
under  the  impression  that  perhaps  the  kinking  caused  the  bile 
to  accumulate  in  the  duodenum,  and  that  the  regurgitation  was 
through  the  pylorus.  For  this  reason  the  pylorus  was  excised, 
with  complete  closure  of  both  the  duodenum  and  stomach  ends; 
yet  this  failed  to  check  the  biliary  vomiting,  showing  conclusively 
that  it  was  the  spur  at  the  opening  alone  which  was  responsible 
for  the  trouble.  Von  Eiselsberg  reports  cases  in  which  he  has 
closed  the  pylorus  by  a  circular  purse-string  suture,  evidently 
with  the  same  idea  which  proved  fallacious  in  this  case. 

The  question  of  the  reduction  of  the  opening  taking  place  in 
the  greatly  dilated  stomach  pari  passu  with  the  contraction  of  the 
stomach  itself  has  been  pretty  well  settled  by  Robson,  Korte,  and 
others.  The  stagnation  is  promptly  relieved,  but  the  hyper- 
dilated  stomach  does  not  contract  greatly,  and  the  lesser  degrees 
of  dilatation  which  regain  normal  size  do  not  materially  afiFect 
the  anastomotic  opening.  Carle  and  Fantino  have  shown  con- 
clusively that  small  quantities  of  bile  are  to  be  found  in  the  stomach 
after  gastro-enterostomy,  and  that  it  does  not  lead  to  trouble. 
Ferrier  and  others  have  connected  the  gall-bladder  directly  with 
the  stomach  without  interfering  with  digestion.  The  pancreatic 
juice  cannot  be  the  cause,  as  Stendel  has  experimentally  divided 
the  jejunum,  fastening  the  open  end  to  the  stomach  and  closing 


COMPLICATIONS    FOLLOWING    GASTRO-KNTKUOSTO.MY  157 

the  duodenum  completely  at  the  severed  point,  causing  all  the 
biliary  and  pancreatic  secretions  to  pass  through  the  stomach, 
yet  no  harm  resulted.  This  was  also  true  of  JMoynihan's  case, 
in  which  this  procedure  was  carried  out  on  the  human  subject. 
McGraw  believes  that  the  views  of  Kelling  are  correct,  and  that 
it  is  the  distention  of  the  duodenum  which  is  rcsponsil)le  for  the 
bad  effects.  The  fact  remains  that  entero-anastoraosis  between 
the  proximal  and  distal  loops  of  the  intestine  short  circuiting  these 
secretions  relieves  the  condition.  The  possibility  of  secondary 
spur  formation  following  gastro-enterostomy  for  ulcer  in  which 
the  pylorus  is  open  must  be  borne  in  mind,  and,  if  possible,  excision 
of  the  ulcer  is  to  be  preferred.  This  the  writer  has  been  able  to 
do  three  times  for  gastric  ulcer  and  once  for  duodenal.  It  has 
been  advocated,  especially  in  this  country  by  Robert  Weir,  to 
perform  an  entero-anastomosis  in  all  cases  of  gastro-enterostomy 
at  the  ])rimary  operation.  This  is  certainly  logical  in  cases  under 
consideration  in  which  the  pylorus  is  open. 

We  have  preferred  the  simple  operation  of  entero-anastomosis 
rather  than  the  more  elaborate  methods  of  Roux  and  others,  and 
in  only  one  case,  that  a  posterior  operation,  has  relief  failed  to 
result.  This  was  due  to  the  fact  that  the  jejunum  was  anasto- 
mosed so  close  to  its  origin  as  to  prevent  proper  drainage  from  the 
proximal  side  through  the  interintestinal  fistula. 

Case  IV. — Gastro-enterostomy  Followed  by  Entero-anastomosis, 
Pylorcctomy,  Eniero-anasiomosis ;  Roux's  Operation;  Death. — Mrs. 
J.  M.,  aged  forty-two,  Scandinavian,  housewife,  one  child,  was 
admitted  to  St.  Mary's  Hospital  on  June  19,  1901.  Typical 
history  of  chronic  ulcer  of  the  stomach.  For  three  years  symptoms 
nearly  constant — vomiting,  ])ain,  loss  of  weight  and  strength; 
confined  to  bed  for  several  weeks  previous  to  admission  to  the 
hospital,  and  for  some  months  has  required  opiates  more  or  less 
constantly.     Personal  and  family  history  good. 

Physical  Examination. — Emaciation  marked.  Painful  area  in 
epigastrium.     Stomach  not  increased  in  size.     Free  acid. 

June  !20th,  posterior  gastrojejunostomy;  ]Murphy  button. 
Attachment  to  jejunum  about  six  inches  from  its  origin.  Stomach 
not  dilated,  pylorus  open;  location  of  ulcer  could  not  be  accurately 


158  WILLIAM   J.    MAYO 

determined  on  account  of  perigastric  adhesions.  Gall-bladder 
contained  one  stone,  evidently  "slumbering,"  as  there  were  no 
evidences  of  disease  about  this  viscus.  Stone  removed  and  gall- 
bladder drained  through  stab  wound  on  the  right  side.  Patient 
discharged  in  good  condition  on  the  twentieth  day,  July  24,  1901, 
readmitted;  one  week  before  had  commenced  to  have  attacks  of 
burning  pain  in  the  stomach,  and  since  had  regurgitated  a  little 
bile- stained  fluid  at  frequent  intervals.  Gastric  lavage  failed  to 
relieve  the  symptoms. 

June  25th,  entero-anastomosis.  Operation  difficult  and  un- 
satisfactory on  account  of  the  short  length  of  the  afferent  intestine, 
and  when  completed,  the  interintestinal  fistula  was  on  a  level  with 
the  gastric  opening  and  only  about  two  inches  from  it.  Gastro- 
enterostomy contracted  to  less  than  the  tip  of  the  little  finger,  and 
angulation  of  the  attached  jejunum. 

The  patient's  condition  improved  rapidly,  and  for  a  time  she 
was  apparently  relieved.  October  12th  she  was  readmitted,  with 
all  the  old  symptoms  in  an  aggravated  form.  Under  the  impres- 
sion that  the  biliary  and  pancreatic  secretions  entered  the  stomach 
through  the  pylorus,  on  October  14th  pylorectomy  was  performed, 
and  the  duodenum  and  stomach  completely  closed  by  a  purse- 
string  suture.  No  relief.  October  18th  a  second  button  entero- 
anastomosis  was  made.  This  was  a  mistake,  as  between  the 
previous  entero-anastomosis  and  the  origin  of  the  jejunum  there 
was  less  than  three  inches.  Some  relief  was  experienced  for  a 
few  days.  October  30th  the  previous  symptoms  had  returned 
with  increased  severity,  and,  as  the  patient  was  becoming  ex- 
hausted; as  a  final  resort  the  operation  of  Roux  was  performed. 
The  adhesions  from  the  previous  operations  rendered  this  ex- 
tremely difficult.  The  jejunum  was  divided  as  closely  as  possible 
to  the  last  entero-anastomosis,  and  the  distal  end  turned  in  by  a 
purse-string  suture.  Less  than  an  inch  of  jejunum  projected 
on  the  proximal  side.  A  Murphy  button  was  inserted  and  with 
some  difficulty  secured  in  position.  A  loop  of  bowel  16  inches 
below  was  attached  laterally.  Patient  returned  to  bed  in  bad 
condition  and  died  thirty-six  hours  later. 


This  brings  up  the  question  as  to  how  long  a  loop  of  jejunum 
should  be  made  above  the  point  of  anastomosis.  Robson  says 
that  for  the  anterior  method  12  inches  is  about  right,  and  for  the 
posterior  somewhat  less.  Mikulicz  says  that  15  c.c.  is  the  neces- 
sary amount  for  the  posterior  operation  and  50  c.c.  for  the  anterior 


COMPLICATIONS    FOLLOWINC;    CASTRO-ENTEROSTOM V  l.l!) 

operation.  Wo  have  averaj^'ed  ahout  14  inches  for  the  anterior 
method,  and  since  the  unfortunate  termination  of  the  case  referred 
to,  not  less  than  ten  inches  for  the  posterior.  Meyer  reports  a 
ease  in  which  fifteen  centimeters  proved  to  be  too  short  for  con- 
venience at  a  secondary  operation.  Peterson,  from  the  Heidel- 
berg clinic,  calls  attention  to  the  fact  that  the  origin  of  the  jejunum 
is  at  a  higher  level  than  the  site  of  the  anastomosis  in  the  posterior 
operation.  This  would  place  the  pro.ximal  portion  of  the  jejunum 
above  the  opening,  and  he  believes  that  the  absence  of  pernicious 
vomiting  in  the  cases  in  Czerny's  clinic  is  due  to  this  cause,  although 
it  is  evident  that  the  location  of  the  opening  on  the  posterior  wall 
of  the  stomach  must  in  these  cases  have  been  at  an  inferior  point, 
and  it  is  probable  that  the  advantage  may  lie  in  this  feature  of 
the  operation.  If  the  obstruction  at  the  pylorus  be  permanent, 
there  can  be  no  objection  to  the  short  length  of  jejunum  above, 
but  if  an  open  pylorus  threatens  contraction  and  spur  formation, 
this  may  prove  unfortunate.  The  last  com])lication  to  be  brief]y 
referred  to  is  the  possibility  of  the  small  bowel  passing  through  the 
loop  of  intestine  above  the  anastomosis.  This  danger  is  much 
greater  with  the  anterior  than  with  the  posterior  method.  Case  V 
so  well  illustrates  this  condition  as  to  need  no  further  comment. 

Case  V. — Anterior  Gastro-enterosfomy;  Secondary  Operation 
for  the  Relief  of  a  Twist  at  the  Anastomotic  Opening  Caused  by  Small 
Intestine  Passing  Through  the  Loop. — R.  X.  S.,  male,  aged  forty- 
one  years,  American,  barber,  was  admitted  to  St.  Mary's  Hospital 
January  1,  1901,  with  the  following  history:  For  several  years 
has  suffered  from  attacks  of  burning  pain  in  the  epigastric  region 
lasting  a  few  minutes  at  a  time,  but  recurring  at  intervals  of 
several  hours.  Much  worse  when  at  work  at  his  trade.  These 
"cramps"  lasted  several  weeks  at  a  time,  after  which  there  would 
be  an  interval  of  weeks  or  months  of  good  health.  For  several 
months  he  has  had  more  or  less  stomach  trouble,  and  occasionally 
vomited.  The  distress  caused  him  to  eat  sparingly,  and  he  has 
lost  '■2o  pounds  in  weight.  He  had  an  attack  of  appendicitis  with 
an  abscess  some  years  ago;  the  abscess  was  incised,  but  the 
appendix  was  not  removed.  He  has  had  a  right  inguinal  hernia 
for  many  years. 

Examination. — A  spare  man,  six  feet  one  inch  in  height, 
emaciation  noticeable.     With   the  exception   of  the  stomach,   no 


160  WILLIAM   J.    MAYO 

feature   of  interest.     Painful   point   in  epigastrium.     Free   acid; 
greater  curvature  of  stomach  three  inches  below  the  umbilicus. 

Diagnosis. — Pyloric  obstruction  from  ulcer.  January  2d,  an- 
terior gastrojejunostomy;  Murphy  button;  appendectomy  and 
Bassini  operation  on  hernia.  An  ulcer  existed  at  the  pylorus, 
extending  to  the  lesser  curvature,  irregular  contour,  size  of  last 
phalanx  of  forefinger.  Evidently  partially  cicatrized  and  obstruct- 
ing pylorus.  On  the  fourteenth  day  symptoms  of  intestinal 
obstruction  occurred,  lasting  forty-eight  hours.  Condition  re- 
lieved by  gastric  lavage  and  rectal  feeding.  Button  passed  on  the 
sixteenth  day;  evidently  cause  of  symptoms.  Discharged 
January  18th;  gained  rapidly  in  weight  and  strength.  For  a 
year  he  remained  in  good  health,  although  complaining  that  if 
he  stood  erect  he  had  a  "drawing  feeling"  in  his  stomach.  From 
this  time  to  May  14,  1902,  when  he  was  readmitted  to  the  hospital, 
he  had  slowly  developed  all  the  former  symptoms  of  obstruction 
at  the  outlet  of  the  stomach,  and  had  a  constant  pain  in  the 
abdomen,  centering  below  the  umbilicus.  May  15th  abdomen 
opened.  Gastrojejunal  orifice  nearly  obliterated  and  stretched  to 
an  inch  in  length.  Jejunum  twisted  at  the  site  of  anastomosis, 
one-half  turn  from  the  left  to  the  right.  Somewhat  more  than 
one-haK  of  the  small  intestine  had  passed  through  the  loop  of 
jejunum  between  the  origin  of  the  jejunum  and  the  attachment 
to  the  stomach.  The  point  of  entrance  was  on  the  right  side, 
beneath  the  transverse  colon.  The  traction  weight  of  the  intes- 
tines upon  the  mesentery  at  the  inferior  margin  of  the  loop  had 
caused  the  volvulus.  The  mesentery  at  this  point  was  much 
thickened.  The  intestines  were  replaced,  the  gastrojejunal  fistula 
divided,  and  the  opening  into  the  stomach  closed.  The  opening 
into  the  jejunum  was  inclosed  by  a  purse-string  suture,  half  of  a 
Murphy  button  introduced,  and  a  posterior  gastrojejunostomy 
made.  The  pyloric  stricture  was  nearly  complete;  the  ulcer  evi- 
dently cicatrized.  It  is  probable  that  the  part  of  jejunum  imme- 
diately below  the  anastomosis  passed  through  the  loop  first,  pro- 
ducing the  twist  which  was  so  prominent  a  feature  on  opening  the 
abdomen.  When  this  happened  is  hard  to  tell — probably  not  for 
some  months  after  the  operation.  When  the  process  once  began, 
it  might  be  expected  to  continue  until  such  an  amount  of  intestine 
traveled  over  the  loop  as  to  pull  the  mesentery  taut,  the  symptoms 
increasing  as  the  condition  gradually  developed.  It  is  possible 
that  at  the  time  the  juncture  was  effected  a  slight  twist  may  have 
occurred. 


THE  RADICAL  CURE  OE  CANCER  OE  THE 

STOMACH* 

WILLIAM    J.    MAYO 


('uiK-er  of  the  sloiiiiuli  is  a  hopeless  malady  unless  il  can  be 
cured  hy  operation.  The  only  excuse  for  the  apathy  of  the  medical 
profession  as  regards  this  condition  is  a  belief  that  it  is  hopeless, 
whether  operated  upon  or  not.  I  do  not  believe  that  such  a  con- 
clusion is  justified  by  the  facts.  In  cancer  of  practically  all  the 
other  organs  operation  is  urged  even  enthusiastically  by  men  who 
look  with  disfavor  upon  the  surgical  relief  of  malignant  disease  of 
the  stomach.  W.  G.  Macdonald  found  records  of  43  cases  of  un- 
doubted cure  after  extirpation  of  cancer  of  the  stomach.  Murphy 
collected  189  cases  operated  upon  radically  by  Kronlcin,  Maydl, 
Rydygier,  Czerny,  Morison,  Bevan,  and  Mayo,  with  26  deaths. 
Of  these,  17  survived  three  years— about  8  per  cent.  This  per- 
centage was  reduced  to  5  per  cent,  by  recurrences  after  three  years, 
but  as  many  of  these  cases  were  alive  and  apparently  well  less  than 
three  years,  the  law  of  averages  might  be  expected  to  at  least  main- 
tain the  8  per  cent,  or  better  it  in  due  time. 

Are  the  results  of  radical  operations  for  cancer  of  the  cervix 
uteri,  for  example,  nuich  better  than  this?  If  8  per  cent,  of  cases 
of  cancer  of  the  stomach  can  be  cured  by  radical  operation,  this  dis- 
couragement is  not  justified,  neither  is  it  creditable  to  us  as  a 
profession.  One-third  of  all  cases  of  carcinomatous  disease  is 
located  in  the  stomach.  The  condition  has  not  received  a  fair 
.share  of  attention  from  a  surgical  standpoint. 

Take  another  point  of  view:    What  has  been  the  result  in  the 

*Read  by  invitation  before  the  New  York  Medical  Association  October  ii, 
imH.     Reprinlod  from  "The  St.  Paul  Medical  Journal,"  December.  1904. 
VOL.  I— 11  Kil 


162  WILLIAM   J.    MAYO 

cases  in  which  recurrence  has  manifested  itself?  Kronlein's 
statistics  are  the  most  available  for  consideration.  The  unope- 
rated  usually  died  within  the  year,  gastro-enterostomy  prolonged 
life  on  an  average  three  months,  and  radical  operation  gave  an 
increase  of  fourteen  months  over  the  unoperated.  Mikulicz  in  100 
cases  had  an  average  duration  of  life  following  operation  of  one 
and  one-third  years.  The  relief  usually  lasts  until  shortly  before 
death,  and  there  is  not  that  prolonged  and  hopeless  illness  which 
characterizes  the  unoperated  cases.  The  patient  has  not  only  the 
hope  of  cure,  but  a  possibility  of  it. 

Why  are  the  results  of  extirpation  of  cancer  of  the  stomach 
not  better?  Because  the  diagnosis  is  not  made  sufficiently  early. 
The  stomach  is  a  favorable  organ  for  operation;  it  has  a  large 
blood-supply  from  several  sources.  It  can  be  rendered  relatively 
sterile,  and  at  least  60  per  cent,  of  carcinomata  are  situated  in  the 
pylorus,  the  most  movable  and  accessible  part  of  the  organ.  The 
tendency  to  lymphatic  infection  is  probably  less  in  cancer  of  the 
stomach  than  in  similar  conditions  in  the  breast,  uterus,  or  rectum 
(Macdonald) . 

In  802  collected  cases  McArdle  found  40  per  cent,  relatively  free 
from  important  lymphatic  involvement,  and  Shaw  demonstrated 
that  18  per  cent,  of  cases  of  cancer  of  the  stomach  which  came  to 
autopsy  had  absolutely  no  secondary  involvement. 

The  physician  has  been  taught  to  believe  that  the  presence  of 
a  tumor  contraindicates  an  operation,  and  unless  one  can  find  a 
tumor,  the  diagnosis  is  uncertain.  He  is  put  in  the  position  of  be- 
ing asked  to  make  a  diagnosis  of  cancer  and  take  the  responsibility 
of  a  perhaps  unnecessary  exploration.  We  should  not  ask  for  a 
diagnosis  of  cancer,  but  we  should  ask  that  a  suspicion  of  malig- 
nant disease  demands  a  surgical  consultation  quite  as  often  as 
appendicitis  or  ectopic  pregnancy.  In  cases  of  doubt  the  patient 
should  be  permitted  to  exercise  a  choice  as  to  an  exploration. 

Some  years  ago  an  eminent  authority  expressed  the  opinion 
that  the  presence  of  a  tumor  of  itself  demonstrated  the  incurability 
of  the  disease.  This  dictum  must  at  least  be  qualified.  A  small 
movable  tumor  in  the  pyloric  region  with  obstructive  symptoms 


RADKAL  rURE  OF  CANCER  OF  STOMACH  1(53 

is  a  favorable  consideration.  Many  patients  die  from  starvation 
without  secondary  involvornont,  and  the  niovahility  argues  for  a 
freedom  from  adliesions  wiiich  complicate  operations  and  increase 
the  primary  mortality.  From  our  own  experience  we  would  judge 
that,  with  symptoms  warranting  an  exploration,  the  lack  of  defi- 
nite signs  usually  means  an  extensive  and  hopeless  involvement 
of  the  body  of  the  stomach.  Had  the  pylorus  been  involved, 
obstructive  phenomena  would  have  given  far  earlier  warning.  A 
large  tumor  or  one  indefinite  in  outline  or  of  fixed  character  would 
be  a  different  question  and  lead  to  a  doubtful  opinion. 

Another  source  of  delay  is  the  prolonged  and  usually  unavail- 
ing attempt  to  make  a  diagnosis  through  various  tests  of  the  stom- 
ach-contents. After  long  and  painstaking  experience  with  lab- 
oratory methods  for  the  early  diagnosis  of  cancer  of  the  stomach 
we  have  been  forced  to  the  conclusion  that  they  do  not  amount  to 
much,  although  late  in  the  disease  they  are  fairly  reliable  guides. 
I  do  not  wish  to  discourage  such  examination — it  is  an  effort  in  the 
right  direction,  and  I  hope  will  lead  to  increased  precision  in  the 
future,  but  in  any  event  it  should  not  lead  us  to  procrastinate. 

Given  a  previously  healthy  person  of  middle  age  or  beyond, 
who  is  beginning  to  lose  weight  and  strength  with  loss  of  appe- 
tite and  slow  and  more  or  less  painful  digestion,  we  should  sus- 
pect cancer.  If,  after  thorough  examination  by  all  the  methods 
at  our  command,  adequate  reason  for  the  condition  is  not  forth- 
coming in  a  few  weeks  at  most,  we  should  advise  exploration. 
Should  this  become  the  practice,  cancer  of  the  stomach  would 
give  as  favorable  a  showing  as  cancer  of  the  breast  or  uterus.  If 
the  profession  awakes  to  its  responsibility,  the  general  public  will 
become  educated.  I  would  emphasize  the  necessity  of  obtaining 
a  careful  history.  A  very  large  proportion  of  the  cases  which  we 
have  had  gave  an  early  history  of  ulcer  of  the  stomach.  Graham 
gave  this  his  attention,  and  found  it  to  be  the  case  in  over  one- 
half  of  all  the  patients  coming  under  our  observation.  In  several 
instances  operation  revealed  the  cicatrix  of  former  ulceration  to 
be  undergoing  malignant  degeneration.  This  is  more  forcefully 
brought  to  mind  by  the  frequency  with  which  competent  men  take 


164  WILLIAM   J.     MAYO 

just  the  opposite  view — that  a  history  of  previous  ulcer  argues  for 
a  return  of  the  ulcerative  process  and  against  malignancy. 

In  our  experience,  cancer  of  the  pyloric  region  has  been  the 
only  form  of  the  disease  which  we  have  been  able  to  diagnosticate 
sufficiently  early  to  attempt  radical  relief.  Many  times  the  proc- 
ess is  distinctly  ring  like,  with  comparatively  little  lateral  involve- 
ment. These  cases  give  early  evidence  of  retardation  of  the  prog- 
ress of  food  from  the  stomach.  The  repeated  finding  of  material 
left  from  the  evening  meal  in  the  morning  washings  from  the 
stomach  is  an  easy  way  to  determine  that  obstruction  exists  or 
the  test-meal  method  may  be  used. 

By  distending  the  stomach  with  air,  not  only  can  its  outline  be 
palpated,  but  often  a  tumor  may  be  brought  up  within  reach  of 
the  palpating  hand.  With  an  ordinary  stomach-tube  and  a  David- 
son syringe  this  can  be  safely  done,  air  being  permitted  to  escape 
or  more  pumped  in  at  will.  This  procedure  is  more  efl:"ective  be- 
cause always  under  perfect  control.  The  bicarbonate  of  soda  and 
tartaric  acid  test  is  painful  and  does  not  always  last  sufficiently 
long,  neither  has  it  the  element  of  safety.  Behrend  reports  three 
deaths  following  its  use,  the  sudden  and  uncontrollable  distention 
doing  fatal  mischief  to  the  diseased  gastric  wall. 

These  simple  means  for  practical  examination  are  at  the  com- 
mand of  every  practitioner,  and  while  he  may  not  arrive  at  as  ac- 
curate results  as  the  trained  specialist,  he  may  at  least  have  his 
suspicions  aroused  in  time  to  give  the  patient  a  chance  for  his  life. 

The  surgical  exploration  presents  no  difficulty  as  to  the  pres- 
ence of  gross  lesions,  and  usually  the  malignant  nature  of  the 
trouble  is  manifest.  Occasionally,  however,  an  ulcer  will  have  so 
great  an  amount  of  new  tissue  about  it  as  closely  to  resemble  can- 
cer. We  have  been  misled  twice — once  removing  an  ulcerous 
pylorus  with  the  idea  that  it  was  cancer,  and  once  removing  a  py- 
lorus with  an  epitheliomatous  ulcer,  supposing  it  to  be  a  simple 
ulcer.  This  leads  us  to  the  conclusion  that,  other  things  being 
equal,  every  ulcer  which  can  be  located  should  be  removed  either 
as  a  complete  operation  or  as  a  part  of  the  operative  procedure  indi- 
cated.    It  also  has  the  advantage  of  removing  the  original  source 


RADICAL    CTRE    OF    CANCER    OF    STOMAL  II  l()0 

of  disease  and  preventing  secondary  malignant  degeneration  of 
tlie  soar  tissue  involved. 

In  deciding  as  to  the  operable  possibilities,  the  two  most  ini- 
f)()rlaiil  considerations  arc  the  extension  of  the  disease  to  the  neigh- 
boring tissues  and  the  lymphatic  involvement.  As  a  rule,  exten- 
sion to  neighboring  viscera  contraindicates  operation.  Extensive 
adhesions  greatly  complicate  the  operation  and  increase  the  pri- 
mary mortality.  Haberkant  had  a  mortality  of  72.7  per  cent,  in 
cases  with  adhesions,  as  contrasted  with  27.3  per  cent,  without  ad- 
hesions. Lymphatic  involvement,  unless  localized  to  the  vicinity 
of  the  growth,  is  a  hopeless  complication.  In  a  general  way  the 
surgically  removable  glands  lie  in  four  groups — first,  along  the 
lesser  curvature;  second,  along  the  greater  curvature;  third,  about 
the  head  of  the  pancreas;  and  fourth,  in  the  greater  omentum.  In 
all  these  positions  in  favorable  cases  extirpation  may  be  justly  at- 
tempted. It  should  not  be  forgotten  that  a  certain  amount  of 
glandular  hyperplasia  may  be  found  which  is  not  due  to  malig- 
nancy. Such  enlargement  is  often,  if  not  usually,  present  in  any 
form  of  disease  which  permits  fermentation  of  the  gastric  contents. 
Fenger  described  simple  adenopathy  in  the  submaxillary  glands 
in  cancer  of  the  lip,  and  Halsted  has  recorded  cases  in  which 
microscopic  examination  of  enlarged  lymphatic  glands  did  not 
show  carcinomatous  change  in  cancer  of  the  breast. 

jMikulicz  believes  that  the  relief  afiforded  by  pylorectomy  and 
gastrectomy  justifies  the  operation  in  otherwise  favorable  cases, 
even  if  all  the  glands  cannot  be  removed.  Extension  along  the 
lesser  curvature  is  more  unfavorable  than  along  the  greater  curva- 
ture. Robson  advises  that  in  every  case  the  resection  shall  extend 
along  the  lesser  curvature  to  the  gastric  artery,  to  enable  removal 
of  glands  which  are  very  prone  to  infection  and  otherwise  liable  to 
be  overlooked.  It  is  needless  to  say  that  secondary  involvement 
of  the  viscera,  shown  by  ascites,  etc.,  precludes  operation.  There 
is  but  little  tendency  for  the  growth  to  invade  the  duodenum.  In 
a  fair  j)roportion  of  hopeless  cases,  present  or  imminent  obstruction 
indicates  gastro-enterostomy. 

After  purely  exploratory  operations  for  inoperable  disease  I 


166  WILLIAM   J.    MAYO 

wish  to  draw  attention  to  the  value  of  the  permanent  buried  su- 
tures of  silk  or  silver  wire  in  the  strong  fascia  in  order  that  the 
patient  may  be  allowed  to  get  about  at  once  and  leave  the  hospital 
in  a  few  days;  such  patients  do  not  bear  confinement  to  bed  well, 
while  waiting  sound  abdominal  union,  and  often  die  without 
being  able  to  return  to  their  homes  and  friends. 

In  St.  Mary's  Hospital  during  the  past  ten  years  213  operations 
have  been  made  upon  the  stomach:  126  for  non-malignant  disease, 
with  a  mortality  of  slightly  less  than  5  per  cent.;  92  for  malignant 
disease,  with  9  deaths — 10  per  cent.  Over  one-fourth  of  the  latter 
group  were  explorations,  but  in  no  case  did  death  follow  such 
examination. 

Radical  operations  upon  the  stomach  owe  their  inception  to 
the  master  mind  of  Billroth,  although  Pean  and  Rydygier  preceded 
him  in  the  actual  performance  of  pylorectomy.  Billroth  placed 
the  operation  upon  a  sound  footing,  and  brought  it  prominently 
before  the  profession.  He  was  not  enthusiastic  about  it,  and  in 
speaking  of  his  results  said:  "All  the  patients  left  the  operating- 
room  in  shock,  from  which  some  of  them  recovered."  His  mor- 
tality was  55  per  cent. 

The  operation  which  takes  the  name  of  Billroth  consists  in 
exsecting  the  diseased  part  and  narrowing  the  cut  end  of  the  stom- 
ach to  the  size  of  the  duodenum,  and  then  suturing  the  intestine 
into  the  gap.  The  point  at  which  the  three  angles  came  together 
so  often  gave  way,  with  resultant  leakage  and  death,  that  it  re- 
ceived the  name  of  the  "fatal  suture  angle."  Kocher  was  one  of 
the  first  to  see  the  defect  in  the  Billroth  operation,  and  made  a 
radical  departure  from  it,  suturing  the  cut  end  of  the  stomach 
completely  and  inserting  the  duodenum  in  an  independent  posi- 
tion upon  the  posterior  gastric  wall.  This  is  a  most  excellent 
method,  but  it  occasionally  happens  that  the  traction  necessary  to 
adjust  the  duodenum  to  the  greatly  shortened  stomach  has  a  ten- 
dency to  obstruct  the  opening.  In  seven  operations  with  the 
Kocher  method  we  had  one  such  case,  and  were  compelled  later  to 
do  a  gastrojejunostomy.  In  13  pylorectomies  since  that  time  we 
have  closed  both  the  duodenum  and  the  stomach  ends,  making  a , 


i£Ai)i(  Ai.  rrui:  OF  cANc  i;h  of  sroMAfH  167 

gastrojejunostomy  of  the  usual  type  at  once.  All  in  all,  this  has 
proved  the  most  satisfactory  method  of  ojjeraticjn.  Pyloreetomy 
and  partial  gastrectomy  are  rK)t  more  difficult  than  similar  opera- 
tions upon  the  })reast,  uterus,  or  rectum.  We  have  founrl  the  fol- 
lowing technic  simple  and  satisfactory: 

Through  a  median  incision,  having  its  inferior  angle  at  or 
slightly  to  the  left  of  tiie  umbilicus,  the  stomach  is  exposed,  and 
the  gastrohepatic  omentum  tied  as  far  to  the  left  as  the  gastric 
artery.  This  mobilizes  the  diseased  part,  and  by  passing  the  fingers 
behind  the  pylorus  in  the  lesser  cavity  of  the  peritoneum,  the 
gastrocolic  omentum  can  be  tied  off  without  danger  to  the  superior 
mesenteric  artery.  A  gauze  pad  is  drawn  under  the  freed  part,  and 
a  heavy  clamp  placed  on  the  duodenum  with  sufficient  force  to 
form  a  groove.  A  catgut  ligature  is  tightly  tied  in  this  groove,  and 
a  clamj)  placed  on  the  stomach  side  and  the  duodenum  divided 
just  beyond  the  ligature.  A  silk  purse-string  suture  about  the 
duodenum,  three-fourth  inch  below,  enables  the  tied  end  to  be 
invaginated  in  a  similar  manner  to  the  stump  of  the  appendix. 
The  stomach  is  turned  up  and  to  the  left,  and  heavy  clamps  placed 
an  inch  from  the  growth.  In  the  sulcus  formed  by  the  pressure  a 
continuous  catgut  shoemaker's  stitch  is  placed,  using  one  thread 
with  a  needle  at  each  end.  The  diseased  part  is  then  severed,  and 
a  continuous  silk  Gushing  suture  rolls  in  the  first  suture  line.  In- 
dependent gastro-enterostomy  with  the  Murphy  button  is  then 
performed,  either  upon  the  anterior  or  the  posterior  wall  of  the 
stomach,  as  preferred.  The  operation  is  done  quickly  without  loss 
of  blood  or  opening  the  stomach. 

Our  experience  of  20  pylorectomies  with  3  deaths  is  too  small 
to  draw  conclusions  from,  yet  in  a  general  way  we  can  say  that  the 
results  of  these  radical  operations  upon  the  stomach  have  proved 
as  satisfactory  as  upon  the  breast,  uterus,  or  rectum.  The  mor- 
tality of  IG  per  cent,  cannot  be  considered  excessive  when  it  is 
noted  that  this  includes  those  early  cases  in  which  misfortune  so 
often  attends  inexperience.  One  of  our  cases  of  pyloreetomy  and. 
partial  gastrectomy  lived  three  years  and  five  months  and  then 
died  after  a  short  illness  from  secondary  involvement  of  the  liver. 


168  WILLI  Ail    J.    iL\YO 

While  we  have  no  other  case  which  hved  beyond  the  three-year 
limit,  we  have  several  favorable  cases  which  maj^  be  expected  to 
afford  good  results. 

As  to  complete  gastrectomy^,  there  is  not  much  to  be  said.  The 
cases  are  too  few  and  the  time  too  short.  We  have  twice  removed 
practically  all  the  stomach,  but  in  each  instance  enough  of  the 
gastric  wall  remained  to  make  the  jejunal  attachment.  In  neither 
of  these  cases  was  there  that  sagging  of  the  stomach  and  dragging 
down  of  the  esophagus  which  made  the  operation  of  Schlatter, 
Richardson,  and  others  so  successful. 

In  conclusion,  let  us  put  this  question  to  the  practitioner  of 
medicine:  Can  you  cure  a  case  of  cancer  of  the  stomach?  If  not, 
why  withhold  the  only  known  means  of  effecting  such  a  cure — a 
surgical  operation?  Again  let  us  ask,  can  you  diagnosticate  can- 
cer of  the  stomach  early  enough  for  surgical  relief?  if  not,  why 
withhold  an  exploration,  the  only  certain  means  of  diagnosis? 


THE  PRESENT  STATUS  OF  SURGERY  OF  THE 

STOMACH* 

WILLIAM    J.    MAYO 


We  have  recently  gone  over  the  records  of  somewhat  over  900 
operations  upon  the  organs  contained  within  the  upper  abdominal 
zone.  In  reviewing  the  histories  of  these  cases  a  number  of  points 
of  interest  were  noted.  One  of  the  most  notable  features  was  the 
exceedingly  close  relationship  which  existed  between  the  gall- 
bladder and  bile-passages,  the  stomach  and  duodenum,  and  the 
pancreas.  The  association  of  function  and  the  continuity  of 
mucous  surface  make  the  disease  of  any  one  organ  a  menace  to  the 
integrity  of  the  others.  The  gall-bladder  and  stomach  were  the 
organs  primarily  affected  in  tlie  large  majority  of  cases.  The 
duodenum,  from  its  peculiar  situation,  seemed  to  act  as  a  buffer, 
and  was  secondarily  involved  from  gall-stone  disease  and  gastric 
ulcer  in  about  an  equal  proportion  of  cases.  In  the  latter  instance 
the  ulcer  was  in  the  first  portion  of  the  duodenum,  seemingly  due 
to  the  acid  gastric  secretions  eroding  the  mucous  membrane  at 
a  point  above  the  opening  of  the  common  duct,  with  its  alkaline 
fluids.  The  pancreas  was  also  usually  affected  secondary  to  gall- 
stone disease  or  a  duodenitis. 

It  is  not  to  be  wondered  that  it  has  been  difficult  to  arrive  at 
the  exact  pathologic  diagnosis  in  many  of  these  cases,  particularly 
since  this  field  of  work  is  comparatively  new.  Abdominal  surgery 
owes  much  to  pelvic  surgery,  which  was  first  in  the  field;  the  ease 
of  diagnosis  and  the  remarkable  results  of  operative  procedures 

*The  .\nmial  Address  in  Surgery,  read  at  the  annual  meeting  of  the  Stiite 
Medical  Society  of  Wisconsin,  Milwaukee,  June  4,  1903.  Reprinted  from  "Xorlh- 
western  I>jincet,"'  July  1,5.  1903. 

Hi!) 


170  WILLIAM   J.    MAYO 

in  the  pelvis,  as  contrasted  with  the  fatahty  of  the  surgery  of  the 
abdomen,  gave  an  impetus  to  abdominal  work  which  at  once 
placed  it  to  the  front  and  rendered  it  the  pride  of  professional 
achievement.  Experience,  gained  ofttimes  as  the  result  of  mis- 
taken zeal  in  the  performance  of  unnecessary  and  mutilating 
operations  upon  the  ovaries  and  tubes,  and  later  the  uterus,  has 
since  been  turned  to  good  account  in  the  territory  of  gastro-intes- 
tinal  disease.  Pelvic  surgery  has  reached  its  place — much  more 
conservative  and  less  often  resorted  to  than  it  was  five  to  ten  years 
ago.  The  appendix,  after  much  discussion,  has  also  reached  its 
proper  position  in  surgery,  and  as  much  can  be  said  of  gall-stone 
disease,  the  extent  and  importance  of  which  have  only  of  late  come 
to  be  appreciated. 

I  believe  that  the  stomach  is  destined  to  play  a  great  part  in 
the  surgery  of  the  future.  Just  as  the  appendix  followed  pelvic 
surgery — to  be  accepted  and,  in  turn,  replaced  by  the  diseases  of 
the  gall-bladder,  so  now  the  stomach,  and  vrith  it  the  correlated 
duodenum  and  pancreas,  is  to  be  the  center  of  surgical  observation. 
It  is  one  of  the  curious  phases  of  modern  medicine  that  surgery  leads 
the  way.  With  the  accumulated  experience  of  thousands  of 
postmortem  revelations,  how  little  did  we  know  of  diseases  of  the 
ovaries  and  tubes,  extra-uterine  pregnancy,  and  appendicitis.' 
Gall-stones  were  looked  upon  as  innocent  autopsy  findings,  and 
today  the  correct  interpretation  of  gastric  phenomena  is  in  an 
equally  unsatisfactory  condition. 

Surgery  of  the  stomach  has  been  slow  to  advance — it  had  to 
live  down  a  bad  name.  The  early  operations  of  the  Billroth 
school  for  cancer,  before  modern  abdominal  surgery  was  properly 
understood,  gave  a  discouraging  mortality,  the  statistics  of  which 
still  hamper  and  embarrass  our  work.  Billroth,  with  the  courage 
of  conviction,  attacked  malignant  disease  of  the  gastric  cavity, 
because  then,  as  now,  it  was  the  victim's  only  chance.  Nor  was 
the  condition  of  benign  disease  much  better.  Operations  for  the 
deadly  complications  of  ulcer,  such  as  perforation  and  hemorrhage, 
gave  a  frightful  mortality;  no  wonder  that  this  work  has  been 
looked  upon  with  dread  by  the  physician,  and  that  he  has  con- 


PRESENT    STATUS    OF    Sl'IUiEKV    OF    TIIK    STOMATH  171 

liiiiicil  "tlic  sins  of  medical  omission,"  lia\'iii^  the  results  of  "siir- 
gieul  c-oinmissioM"  before  his  eyes. 

Gastric  surgery  has  been  judged  by  its  results  iu  late  operations 
for  cancer  and  fatal  coniplieations  occurring  in  the  course  of 
benign  disease.  We  miglit  as  well  condemn  operations  for  apix-n- 
dieitis  by  the  results  of  surgical  operation  for  the  general  suppu- 
rative peritonitis  which  it  sometimes  caused.  As  a  matter  of  fact, 
the  stomach  is  one  of  the  most  favoral)le  organs  for  operative 
attack.  Easily  accessible  to  a  large  extent  of  its  surface,  with  a 
splendid  blood-supply  from  four  sources,  it  permits  a  freedom  of 
work  and  a  certainty  of  healing  not  exceeded  by  any  organ  in  the 
abdomen,  and  by  no  means  least  in  importance  is  the  fact  tluit 
its  cavity  can  be  rendered  reasonably  sterile  before  operation. 
The  great  difficulty  to  be  surmounted  is  in  obtaining  a  correct 
diagnosis.  We  have  seen  "gastralgia"  disappear  after  the  removal 
of  gall-stones,  and  "dyspepsia"  relieved  by  the  excision  of  the 
chronically  inflamed  appendix.  The  field  of  gastric  surgery  is  be- 
ing gradually  relieved  of  a  number  of  these  parasites  of  diagnostic 
obscurity.  It  will  no  longer  do  to  give  a  blanket  diagnosis  of 
"stomach  trouble,"  and  the  symptoms  of  the  patient,  instead  of 
being  considered  the  disease,  must  be  referred  to  their  proper 
pathologic  source. 

Compare  the  present  knowledge  of  appendicitis  with  the 
comj)lex  symptomatic  diagnosis  of  former  days — obstruction  of 
the  bowels,  inflammation  of  the  bowels,  peritonitis,  etc.;  it  would 
be  tedious  merely  to  name  them.  They  have  gone  the  way  of 
"pelvic  cellulitis."  It  can  be  laid  down  as  an  axiom  that  ignor- 
ance breeds  complexity,  and  one  need  not  be  a  prophet  to  fore- 
tell the  disappearance  of  mo7"e  than  half  of  the  so-called  "diseases 
of  the  stomach"  of  our  medical  text-books. 

Upon  what  shall  we  base  a  diagnosis  of  a  surgical  lesion  of  the 
stomach?  Our  diagnostic  means  can  be  classified  into  three 
groups:  First,  the  history  of  the  ])atient;  second,  the  physical 
outlines  of  the  stomach,  including  the  use  of  the  stomach-tube  to 
develop  stagnation  or  retention  of  food;  and,  third,  laboratory 
methods,  including  test-meals,  chemistry  and  bacteriology,  and 


172  WILLIAM   J.    MAYO 

microscopy.  Graham  and  Millet  have  the  records  of  nearly  1100 
examinations  of  the  gastric  contents  in  conjunction  with  the 
history  of  the  patient  and  the  size  and  position  of  the  stomach 
and  pylorus.  Of  these  patients,  over  300  came  to  operation.  The 
diagnosis,  based  on  the  history  and  physical  outlines  of  the  stomach 
and  the  rational  signs  and  symptoms,  gave  a  correct  diagnosis  in 
over  80  per  cent,  of  the  cases.  The  laboratory  examinations, 
including  test-meals  and  so  forth,  were  of  value  in  only  a  small 
percentage  of  cases,  and  then  only  as  corroboratory  evidence. 
I  do  not  wish  to  discourage  such  tests,  but  simply  to  protest 
against  the  time  spent  in  waiting  until  certain  chemical  phenomena 
appear  before  recommending  operation.  This  is  especially  true 
in  the  early  diagnosis  of  cancer.  Time  and  again  have  we  had 
patients  held  for  weeks  waiting  for  these  supposedly  valuable 
diagnostic  appearances,  until  the  developing  tumor  and  cachexia 
discouraged  the  enthusiastic  diagnostician  and  sent  a  hopeless 
patient  to  the  surgeon. 

Exploratory  incision  is  the  only  hope  for  the  patient  with 
cancer  of  the  stomach,  and  a  suspicion  of  this  disease  should  compel 
the  physician  to  explain,  and  let  the  victim  and  his  friends  choose 
between  exploration  and  procrastination.  In  developing  the 
outlines  of  the  stomach,  an  ordinary  Davidson  syringe  and  a 
stomach-tube  are  sufficient.  In  this  way  air  can  be  pumped 
into  the  stomach  and  allowed  to  escape  again  and  again,  until  a 
careful  mapping  out  is  accomplished.  The  carbonic  acid  gas 
test  is  often  painful,  and  does  not  give  time  enough  for  thorough 
work;  there  are  also  a  number  of  deaths  recorded  from  the  sudden 
distention  rupturing  a  diseased  gastric  wall.  The  use  of  the 
stomach-tube  is  also  very  valuable  in  showing  the  actual  results 
of  gastric  function — not  in  test-meals  necessarily,  but  as  to 
whether  the  ordinary  meal  is  retained  too  long  in  the  stomach.  For 
example,  remnants  of  the  evening  meal  found  in  the  stomach  in 
the  morning  on  several  occasions  indicate  mechanical  obstruction 
at  the  pylorus.  Inspection  for  gastric  waves,  so  commonly  seen 
in  obstruction  at  the  pylorus,  splashing  sounds,  and  so  forth  are 
also  of  value. 


PUKSKNT    ST.\T(  S    OF    St  U(;ERY    OF    TIIK    .STO.MA<  II  17.'} 

It  is  not  my  (Irsirc  to  j^o  into  the  (|iiosti()n  of  differential  dia^'- 
nosis,  l)iil  I  do  wish  to  call  the  at  tcntion  ol"  the  ^'<'neral  practitioner 
to  the  fact  tliat  the  n^fiiieineiils  of  teelinieal  diai^iiosis  are  often 
useless  and  occasionally  harmful  in  causing  delay,  and  that  the 
sensible  practitioner,  with  the  few  siiuple  means  at  his  command, 
is  perfectly  capable  of  arriving  at  a  reasonable  diagnosis,  and 
will  at  least  be  able  to  direct  the  majority  of  his  patients  needing 
surgical  treatment  to  the  surgeon  in  time  to  be  benefited. 

There  are  two  important  groups  of  surgical  lesions  of  the 
stomach:  (1)  Those  of  benign  origin  and  usually  inflammatory 
in  character,  with  ulcer  as  the  type.     ('-2)  Cancer  of  the  stomach. 

Ulcer  of  the  stomach  has  been  heretofore  studied  from  its 
complications,  such  as  perforation  and  hemorrhage,  and  from 
autopsy  findings.  This  has  been  unfortunate,  as  it  has  exaggerated 
fatal  secondary  phenomena  and  has  thrown  but  little  light  upon 
the  condition  during  the  period  of  chronic  disability,  in  which 
surgery  would  be  a  well-planned  attempt  to  cure,  rather  than  a 
last  resort.  Acute  ulcer  is  usually  diagnosticated.  The  fre- 
quency of  sudden  perforation  and  hemorrhage  in  this  variety  of 
lesions  has  enabled  more  accurate  understanding  of  the  subject; 
but  we  must  not  take  these  symptoms  to  be  the  standard  for 
chronic  gastric  ulcer.  In  this  lies  the  frequent  failure  to  recognize 
chronic  ulceration. 

Pain  is  tlie  most  characteristic  symptom  of  the  old  ulcer,  and 
the  nearer  the  lesion  to  the  pylorus,  the  more  cramp-like  the  pain, 
while  in  the  duodenum  it  may  almost  exactly  simulate  gall-stone 
colic.  Chronic  ulcer  causes  slow  and  painful  digestion;  the  pa- 
tient is  careful  of  his  diet,  and  has  usually  one  of  his  own,  the  value 
of  which  experience  has  taught  him.  The  symptoms  are  not 
steady,  and  days  or  weeks  of  distress  are  followed  by  intervals, 
more  or  less  j)rolonged,  of  comparative  comfort.  The  pain 
symptom  is  often  variable,  even  during  the  period  of  one  day, 
one  or  more  meals  giving  no  trouble,  and  the  next  one,  perhaps, 
causing  much  suffering.  Unlike  acute  ulcer,  hemorrhage  and  vom- 
iting are  not  common  symptoms;  the  latter,  a  late  phenomenon, 
is  usuallv  due  to  secondarv  contraction  and  obstruction  at  the 


174  WILLIAM   J.    MAYO 

pylorus.  Acute  ulcer,  and  occasionally  the  chronic  ulcer,  is  usu- 
ally cured  by  rest;  but  the  latter  gets  its  name  because  it  has 
not  been  cured,  and,  like  chronic  appendicitis  and  gall-stones, 
the  same  case  may  be  medically  cured  a  score  or  more  of  times. 
Leube  puts  the  death-rate  of  ulcer  at  25  per  cent.,  and  says  that, 
if  curable,  four  or  five  weeks  should  be  the  limit  of  required  time. 
In  a  very  recent  study  of  500  cases,  treated  at  the  London  Hospital 
between  1897  and  1902,  211  had  had  previous  similar  attacks; 
in  other  words,  were  known  to  have  had  ulcer,  wnth  intervals  of 
apparent  cure.  In  the  remainder  the  symptoms  had  been  more 
or  less  continuous — 18  per  cent,  died  and  42  per  cent,  wxre  not 
cured  at  the  time  of  discharge.  A  total  of  60  per  cent,  died  or 
were  not  cured,  and  of  the  40  per  cent,  of  patients  supposed  to  be 
cured,  who  can  tell  their  future  course?  .^he  large  majority  of 
cases  of  chronic  ulcer  of  the  stomach  are  surgical,  and,  after  a 
reasonable  trial  of  medical  treatment,  should  be  so  considered. 

The  function  of  the  stomach  is  interfered  with  mechanically, 
first,  by  obstruction  at  the  outlet,  which  prevents  proper  egress 
of  the  food;  second,  by  disease  of  the  pyloric  portion,  which 
interferes  with  its  muscular  action;  and,  third,  disease  of  the 
fundus  of  the  stomach,  which  prevents  proper  reservoir  function. 
Pyloric  obstruction  gives  unmistakable  evidence  of  its  presence, 
by  gastric  dilatation,  stagnation,  and  retention  of  food  causing 
fermentation,  late  vomiting,  and  emaciation.  These  cases  are 
seen  in  all  stages,  from  the  slight  temporary  interference  with 
digestion  to  the  most  marked  degree  of  disability.  The  condition 
can  be  aptly  compared  to  a  valvular  heart  lesion;  spells  of  dila- 
tation alternating  with  compensation  through  hypertrophy  give 
periods  of  comparative  health  after  a  more  or  less  prolonged  train 
of  gastric  insufficiency. 

Benign  obstructions  are  usually  the  late  results  of  the  healing 
of  a  gastric  ulcer,  and  many  times  the  symptoms  are  such  as  to 
lead  to  the  diagnosis  of  cancer.  I  have  no  doubt  many  victims 
are  allowed  to  die  under  the  impression  of  a  necessarily  fatal 
ending. 

It  must  not  be  forgotten  that,  like  cancer,  chronic  ulcer  is  a 


PRESENT    STATIS    f)I'    SlIUMOKV    <^)F    THE    STO.MA(H  1  I.) 

cliseusc  ol'  adiilL  life,  in  lliis  rcsijccL  (liU'eriiig  from  llic  aculo  form, 
which  is  moMt  common  in  adolescent  females.  Drainage  oper- 
ations give  m:ir\('loiis  relief  in  hcnign  obstructions  at  the  pylorus; 
a  patient  at  liie  xcrge  of  starvation  in  a  few  weeks  becomes  a 
picture  of  lieallli.  (iastro-enteroslomy  has  been  the  operation 
of  choice,  but  in  certain  cases  the  newer  pyloroplastic  method  of 
Mikulicz  or  the  gastroduodenostomy  of  Finney  is  also  indicated, 
and  gives  in  some  respects  even  more  desirable  results. 

The  second  group  of  cases  is  that  in  which  ulcer  exists  in  the 
muscular  pyloric  region,  preventing  the  pro|)er  mixing  of  the 
food  material.  In  over  ^OO  o])erations  for  benign  disease  of  the 
stomach  we  have  found  ulcers  capable  of  giving  symptoms  requir- 
ing operation,  nearly  always  in  that  segment  of  the  stomach  lying 
to  the  right  of  the  cardiac  orifice,  and  having  the  lesser  curvature 
as  its  sui)erior  border.  Its  inferior  border  on  the  greater  curvature 
does  not  extend  so  great  a  distance  to  the  left  of  the  pylorus.  The 
fundus  of  the  stomach  has  but  feeble  muscular  action;  it  slowly 
compresses  the  food  into  the  pyloric  antrum,  and  the  latter,  by 
a  piston-like  action,  forces  the  food  backward  into  the  fundus, 
as  well  as  forward  into  the  duodenum.  Ulcer  in  the  pyloric 
region  gives  rise  to  great  pain  and  distress  from  the  so-called 
"pyloric  spasm."  The  latter  is  not  confined  to  the  pyloric  sj)hinc- 
ter,  but  to  all  or  any  part  of  this  muscular  region.  The  symp- 
toms are  pain  and  indigestion,  gas,  hypersecretion,  and  so  forth — 
the  "pyloric  syndrome"  of  Hartmann.  Many  of  these  cases 
heal  in  time,  and  the  resulting  cicatrix  produces  the  obstructions 
which  were  discussed  in  group  one.  The  proper  surgical  treat- 
ment of  such  cases  is  not  settled,  and  no  one  method  will  api)ly  to 
all  cases.  The  dilatation  is  not  extreme,  as  the  obstruction  is 
due  to  spasm  and  is  essentially  temporary  in  character.  Gastro- 
enterostomy on  the  cardiac  side,  and  usually  at  a  point  directly 
opposite  the  esophageal  opening,  gives  splendid  temporary  results; 
but  with  the  healing  of  the  ulcer,  which  quickly  takes  ])lace  as 
soon  as  the  food  is  prevented  from  passing  through  the  ulcerated 
area,  the  spasm  relaxes  and  the  pyloric  region  begins  to  func- 
tionate normally.     The  gastro-intestinal  fistula  often  contracts,  or 


176  WILLIAM   J.    MAYO 

the  double  stomach  drainage  of  itself  gives  future  trouble.  The 
plastic  operations  about  the  pylorus,  so  useful  in  benign  strictures, 
are  probably  not  efficient,  since,  no  matter  how  large  the  outlet, 
the  food  must  still  pass  through  the  ulcerated  area  before  reaching 
the  pylorus,  and  that  obstruction  has  no  influence  in  the  produc- 
tion of  ulcer  is  shown  by  the  typical  examples  in  the  duodenum. 

Excision  of  the  ulcer  itself  is  sometimes  feasible,  but,  unfor- 
tunately, the  lesion  is  often  multiple,  and  may  be  hard  to  detect. 
Rodman  suggests  that,  in  certain  cases,  excision  of  the  pyloric 
end  of  the  stomach  should  be  the  operation  of  choice,  as  it  would 
not  only  permanently  cure  the  condition,  but  also  prevent  the 
possibility  of  secondary  malignant  degeneration,  which  has  oc- 
curred not  infrequently. 

The  third  group,  in  which  the  reservoir  function  of  the  stomach 
is  interfered  with,  is  usually  the  result  of  extensive  ulceration  and 
cicatricial  stenosis  in  the  body  of  the  stomach,  causing  hour-glass 
contraction.  It  is  interesting  to  note  that  hour-glass  stenosis 
may  be  multiple,  and  that  a  contraction  of  the  pylorus  also  very 
commonly  exists,  so  that  a  combination  of  gastrogastrostomy 
and  gastro-enterostomy  is  usually  indicated. 

A  few  words  in  regard  to  some  dilatations  of  the  stomach  not 
of  organic  origin,  such  as  the  so-called  atonic  dilatations  often 
found  in  neurasthenic  individuals,  and  without  the  pyloric  syn- 
drome of  Hartmann.  In  these  cases  there  is  no  retention  and 
little  stagnation  of  food.  As  a  rule,  these  patients  are  not  bene- 
fited by  operation.  This  is  also  true  of  gastroptosis,  which  we 
have  found  to  be  present  in  over  half  the  cases  of  movable  kidney. 
Relaxed  conditions  in  the  neurasthenic  state  are  not  often  per- 
manently benefited  by  surgical  operation.  It  is  one  of  the  mis- 
fortunes of  surgical  progress  that  neurasthenic  symptoms  are  too 
often  mistaken  for  organic  disease.  We  have  but  to  look  back 
on  the  discredit  thrown  upon  surgery  by  the  mutilating  operations 
upon  the  pelvic  organs  of  women  to  impel  us  to  go  slow  in  that 
numerous  class  of  neurasthenic  stomachs,  and  before  we  operate 
for  ulcer  let  us  be  sure  the  lesion  exists  elsewhere  than  in  the  mind 
of  the  patient. 


PRESENT   STATLS    OK   SURGERY    OF   TIIJ-:    STOMAfll  177 

In  conclusion,  I  wish  to  speak  hriefly  in  regard  to  cancer  of 
the  stoniacli.  Karly  operation  is  a  prerecjuisile,  and  diaf^nostic 
exploratory  incision  is  necessary.  We  lia\e  operated  upon  113 
cancers  of  the  stoniacli,  of  wliicli  '■27  were  radical  extirpations; 
5  died  within  a  month,  and  one  later  from  another  cause — too 
early  to  know  the  ultimate  result.  Of  the  21  who  recovered,  the 
average  length  of  life  was  over  a  year.  It  is  suri)rising  how  few 
failed  to  live  twelve  months  or  more.  One  lived  three  years  and 
seven  months,  several  are  alive  now  after  more  than  two  years. 
I  am  convinced  that  cancer  of  the  stomach  will  in  five  years  give 
as  good  ultimate  results  after  excision  as  operations  on  the  breast. 
Sixty  per  cent,  of  cancers  are  located  in  the  pyloric  portion — that 
is,  in  the  movable  part  of  the  stomach.  The  lymphatic  arrange- 
ments are  the  same  as  the  vascular,  and  the  dome  of  the  stomach 
is  isolated  from  this  portion,  having  a  different  vascular  and  lym- 
phatic connection.  If  all  of  the  lesser  curvature  with  the  corre- 
sponding lesser  omentum,  and  all  of  the  body  and  greater  curva- 
ture to  the  left  gastro-epiploic  artery,  be  removed  the  results  in 
cancer  of  the  pylorus  should  nearly  equal  what  might  be  expected 
after  complete  gastrectomy.  The  remaining  portion  of  the  stom- 
ach enables  intestinal  anastomosis  to  be  made  with  considerable 
ease,  and  the  gastric  pouch  rapidly  enlarges  to  assume  the  function 
of  the  stomach. 


VOL.  I — \i 


A  REVIEW  OF  303  OPERATIONS  UPON  THE 

STOMACH  AND  FIRST  PORTION 

OF  THE  DUODENUM* 

WITH  TABULATED  REPORT  OF  313  OPERATED  CASES 

WILLIAM   J.    MAYO 


Functionally,  the  small  bowel  begins  at  the  entrance  of  the 
common  duct  of  the  liver  and  pancreas,  a  point  which  marks  the 
primitive  division  between  the  foregut  and  the  midgut  (Hunt- 
ington) .  The  first  portion  of  the  duodenum  may  be  said  to  be  the 
vestibule  of  the  intestinal  tract,  and  its  diseases  resemble  in  char- 
acter those  of  the  stomach,  rather  than  the  intestine.  In  the  large 
majority  of  instances  lesions  at  this  point  cannot  be  diagnosticated 
accurately  from  similar  diseases  in  the  stomach  which  may  be  due 
to  the  same  causes.  For  this  reason  I  have  associated  all  the  cases 
of  this  description  into  a  single  group  for  the  purpose  of  study. 

Total  number  of  cases,  303.  Of  these,  286  are  taken  from  the 
records  of  St.  Mary's  Hospital,  and  the  remainder  are  from  the 
records  of  the  Minnesota  State  Hospitals  for  the  Insane  at  Roches- 
ter and  St.  Peter.  The  average  age  was  forty-two;  males,  42  per 
cent.;  females,  58  per  cent.    , 

Duodenum:  26  cases,  2  deaths — 7.6  per  cent.  Lesions  of  the 
first  portion  of  the  duodenum  can  be  divided  into  two  groups: 
first,  those  due  to  ulcer,  and,  second,  those  associated  with  gall- 
bladder disease. 

Ulcer  limited  to  the  duodenum  was  found  11  times — 1  acute 
perforating,  2  chronic  perforating  protected  by  adhesions,  5  active, 

*  Read  before  the  Philadelphia  Academj'  of  Surgery,  May  11,  1903.  Reprinted 
from  "Annals  of  Surgery,"  July,  1903. 

*  178 


OPERATIONS    UPON    STOMACH    AM)    DLODENUM  1 7f) 

and  3  cicatricial  contraction  with  ohstructivc  symptoms.  Two 
died  after  operation — one  from  pneumonia  following  excision  of 
the  ulcer,  one  from  exhaustion  after  gastro-enterostomy.  In  3 
cases  the  signs  and  symptoms  were  not  to  be  distinguished  from 
gall-stone  disease,  and  the  operation  was  undertaken  with  the 
supposition  that  the  trouble  was  in  the  gall-l)ladder.  Five  times 
ulcers  existed  upon  both  the  duodenum  and  the  stomach.  Of  the 
16  patients  in  this  group,  14  were  males.  The  duodenum  was  fre- 
quently associated  with  gall-stone  disease,  and  usually  secondary' 
to  it;  but  in  11  cases  the  duodenum  was  the  prominent  feature. 
Five  were  due  to  gall-stone  perforation,  requiring  intestinal  suture. 
In  3  of  these  the  gall-bladder  was  completely  separated  function- 
ally from  the  bile-tract,  and  had  become  an  appendage  to  the 
duodenum.  Four  times  crippling  adhesions  to  the  gall-bladder, 
but  without  stones  or  evidence  of  cholecystitis,  were  encountered, 
requiring  dissection  to  loosen — a  periduodenitis  of  unknown  origin. 
In  one  case  an  inflammation  of  an  accessory  lobe  of  the  pancreas 
was  the  cause  of  dense  adhesions.  All  but  one  of  the  cases  in 
which  the  gall-bladder  was  involved  occurred  in  females.  There 
were  no  deaths  in  this  group.  In  no  instance  was  the  duodenum 
the  seat  of  primary  malignant  disease,  and  in  but  two  was  there 
any  evidence  of  extension  from  pjdoric  cancer,  and  then  it  was  not 
marked.  In  two  patients  the  diagnosis  of  lesions  originating  in 
the  duodenum  was  made  previous  to  operation.  The  differen- 
tiating features  of  these  cases  were  good  appetite,  delayed  pain, 
general  absence  of  vomiting,  and  in  only  one  was  there  hemat- 
emesis.  In  two  cases  there  was  evidence  of  blood  in  the  stool. 
Otherwise  the  signs  and  symptoms  were  similar  to  lesions  of  the 
stomach  or  gall-bladder,  and,  even  in  the  light  of  operative  invest- 
igation, points  of  differentiation  did  not  become  evident.  Our 
experience  leads  us  to  believe  that  surgical  diseases  of  the  duode- 
num are  much  more  frequent  than  has  been  supposed. 

The  subject  of  perforating  and  bleeding  ulcers  of  the  stomach 
has  been  so  thoroughly  dealt  wnth  by  Keen  and  Foote,  Weir,  Rob- 
son,  Rodman,  and  Andrews,  and  lesions  of  a  similar  character  in 
the  duodenum  by  \Yeir,  Murphy,  and  others,  that  it  seems  un- 


180  WILLIAM   J.    MAYO 

necessary  to  dwell  upon  the  few  cases  whicli  have  occurred  in  this 
series.  The  present  discussion  will  be  confined  to  the  results  ob- 
tained, and  some  practical  deductions  based  upon  two  large  classes 
of  cases:  First,  gastric  ulcer  and  associated  causes  of  serious  dis- 
turbance;  second,  cancer  of  the  stomach. 

Stomach:  277  cases,  28  deaths — 10.1  per  cent.  In  the  benign 
group  there  are  168  operated  cases  with  11  deaths  (6.5  per  cent.), 
and  nearly  all  these  operations  were  performed  for  chronic  ulcer 
and  its  late  cicatricial  results.  Included  in  this  class  are  all  the 
non-malignant  obstructions.  The  conditions  calling  for  operation 
were  gastric  pain,  with  or  without  acute  exacerbations,  repeated 
hemorrhages,  emaciation  from  inability  to  retain  sufficient  nourish- 
ment. In  a  few  cases  dilatation  due  to  known  or  unknown  cause 
gave  mechanical  reasons  for  interference.  ^ 

There  is  no  doubt  that  perverted  stomach  secretion  is  the  most 
important  manifestation  in  the  majority  of  cases.  This  is  shown 
by  the  almost  constant  association  of  excessive  secretion  in  ulcer, 
and  the  fact  that  similar  ulcers  in  the  duodenum  are  in  that  part  of 
the  intestine  not  protected  by  the  alkaline  juices  poured  in  through 
the  common  duct.  In  this  connection  most  interesting  informa- 
tion is  furnished  by  those  reported  cases  in  which  a  typical  peptic 
ulcer  has  developed  in  the  jejunum,  immediately  below  a  gastro- 
jejunostomy made  for  the  purpose  of  drainage,  the  lesion  in  the 
jejunum  in  every  particular  resembling  the  original  ulcer  for  which 
the  gastro-enterostomy  was  performed.  In  operating  upon  cases 
of  this  description  the  excessive  amount  of  gastric  secretion  is  con- 
stantly in  evidence,  and  the  results  of  drainage  operations  in  re- 
lieving the  distress  and  healing  the  ulcer  bear  out  the  importance 
of  this  view  of  the  case. 

Attempts  to  classify  ulcers  of  the  stomach  have  been  based 
largely  upon  postmortem  experience  and  accidental  complica- 
tions, such  as  perforation  and  hemorrhage.  Such  classifica- 
tions tend  to  exaggerate  the  importance  of  fatal  complications, 
which  render  surgery  a  desperate  resource  rather  than  a  well- 
planned  effort  at  cure. 

Further  surgical  observations  are  necessary  to  clarify  the  con- 


OPERATIONS    UPON    STOMACH    AM)    IHODKNTM  ISl 

fusion  which  siiitoiiikIs  ^aslric  ulcer.  In  ;iMcui|)l  iii<^  to  ^Toup  our 
ojx'ratcd  cases,  \vc  found  tlial  llicrc  were  such  wide  \ariations  in 
the  coiiditions  present  Ihat  no  orderly  chissilicalion  couhl  bo 
made  on  a  purely  clinical  basis.  In  a  general  way,  the  following 
answered  the  purpose  most  satisfactorily: 

(1)  Round  and  fissure  ulcers:  (a)  Acute;  (6)  chronic.  They 
have  the  distinguishing  feature  that  there  is  but  little  thickening 
about  the  base  of  the  ulcer.  Many  amount  to  little  more  than  a 
fissure,  and  are  closely  associated  with  group  (2). 

(2)  Mucous  erosions;  a  condition  which  nuist  be  accepted 
with  caution. 

(.'3)  Chronic  ulcer  with  a  thickened  base,  usually  irregular  in 
form,  and  probably  an  extensive  variety  of  the  chronic  round  ulcer 

(4)  Benign  obstructions  without  regard  to  cause,  although 
usually  of  infiamuiatory  origin. 

In  our  experience  at  the  operating  table  the  last  two  varieties 
are  most  frequently  met  with.  The  acute  round  ulcer  of  Cruveil- 
hier  occurs  by  preference  in  the  chlorotic  type  of  adolescent  fe- 
males, and  usually  responds  to  medical  treatment.  Operation  is 
most  often  called  for  in  the  acute  cases  by  that  peculiar  perforation 
so  graphically  portraj^ed  by  Rokitansky — "cut  out  by  a  punch"; 
or  by  severe  hemorrhage  from  the  stomach.  Chronic  round  ulcer 
and  fissure  ulcer  do  not  often  lead  to  harmful  cicatricial  contraction, 
on  account  of  their  small  size.  Near  the  pylorus  they  may  be  the 
starting-point  for  a  band-like  stenosis  incircling  the  pyloric  ring. 
Chronic  round  ulcer  is  usually  found  in  adults,  and  in  our  experience 
has  been  more  frequent  in  females.  It  would  seem  that  there  is 
little  difference  between  the  chronic  round  ulcer  and  the  chronic 
cicatricial  ulcer,  except  that  as  the  outer  coats  are  involved  the 
extent  of  ulceration  increases  and  loses  its  characteristic  round  or 
oval  form,  while  usually  a  healing  process  is  apparent  in  some  part 
of  its  extent.  A  subvariety  of  this  group  is  the  "pore-like"  ulcer 
described  by  Murchison,  which  is  met  with  more  often  in  adults 
and  gives  rise  to  grave  hemorrhages,  and  yet  is  so  minute  that  it 
is  difficult  to  locate,  even  at  postmortem.  The  mucous  "erosion," 
limited  to  a  small  area  or  several  such  patches,  was  seen  in  a  few 


182  WILLIAM   J.    MAYO 

instances.  The  large  "mucous  erosion"  described  by  Dieulafoy 
as  giving  rise  to  alarming  hemorrhages  was  not  met  with.  I  am 
unable  to  say  just  how  much  importance  is  to  be  attached  to  the 
surface  erosion  of  limited  extent.  In  the  first  place,  the  detection 
is  difficult.  The  whole  question  of  the  surgical  exploration  for 
round  ulcers  and  erosions  is  one  surrounded  with  difficulty  and 
uncertainty.  There  are  usually  no  external  manifestations  which 
lead  to  location  of  the  lesion,  and  the  only  way  a  diagnosis  can  be 
established  is  to  open  the  stomach  and,  with  a  short,  wide  speculum 
explore  the  interior.  The  margin  of  the  instrument  may  and  fre- 
quently does  produce  a  traumatism  to  the  superficial  mucous  layers, 
and  the  result  is  very  like  the  pathologic, erosion.  We  have  seen 
undoubted  and  typical  examples  covered  with  a  membranous  film 
of  mucous  character  which,  when  brushed  off,  allows  the  nature  of 
the  trouble  to  become  apparent.  The  chief  obstacle  to  accurate 
diagnosis  lies  in  the  surgical  indications.  Round  ulcers  and  ero- 
sions are  often  multiple,  and,  as  a  rule,  do  not  cause  cicatricial 
contraction  at  the  pylorus.  Clinicar  experience  has  demonstrated 
that  drainage  is  the  best  method  of  surgical  treatment  with  which 
we  are  acquainted,  therefore  an  exploration,  however  attractive 
to  the  surgeon,  is  often  not  completed;  but  the  surgical  indications 
are  fulfiled  by  some  form  of  gastro-intestinal  operation,  and  the 
diagnosis  remains  unproved.  The  surgeon  hesitates  to  expose  the 
patient  to  even  a  slight  risk,  for  purely  diagnostic  purpose.  The 
old  adage,  "a  good  prognosis  is  better  than  a  good  diagnosis,"  leads 
to  operations  based  upon  symptoms.  If  round  ulcer  is  found,  ex- 
cision is  the  proper  course;  but  there  is  always  the  chance  that  the 
ulcer  excised  is  not  the  only  one,  and  that  others  may  exist  unde- 
tected or  in  an  inaccessible  situation. 

We  may  well  ask  ourselves  in  such  cases.  Does  an  ulcer  exist? 
Usually,  we  can  answer  yes,  and  base  the  diagnosis  upon  such  symp- 
toms as  would  establish  a  medical  diagnosis.  Clinically,  these 
cases  come  to  us  after  medical  treatment  has  failed  utterly,  and 
either  the  diagnosis  is  unquestioned  or  there  is  secondary  inter- 
ference with  motility,  resulting  in  retardation  or  retention  and 
gastric    dilatation,    giving    mechanical    reasons    for    interference. 


Fig.  12. — Showing  line  for  incision  in  case  of  ulcer  of  the  stomach. 


OPKIfATIOXS    UPON'    STOMACH    AND    DlOlHCNf.M  183 

The  theory  of  jnloric  si)asin  is  most  interesting,  ulthongh  it  slioiild 
be  called  a  hypothesis  rather  than  a  definite  condition.  I  have 
examined  the  pylorus  in  over  300  eases  at  the  pperating  table  with 
a  view  to  estal)lishing  a  normal  pylorus  under  anesthesia.  Usually, 
tlie  normal  pylorus  in  the  anesthetized  i)atient  will  allow  the  thumb 
and  the  forefinger  to  meet  nicely  about  the  caliber  of  a  silver  dime, 
and  under  some  conditions  of  deep  anesthesia  it  may  be  found  di- 
lated to  the  diameter  of  a  silver  twenty-five-cent  piece.  I  am 
satisfied,  however,  that  spasm  of  the  whole  or  some  part  of  the 
pyloric  portion  of  the  stomach  may  and  often  does  take  place,  and 
that  it  is  one  of  the  causes  of  the  retention  of  the  excessive  secre- 
tions and  distress;  but  I  am  by  no  means  sure  that  it  is  confined  to 
the  pyloric  sphincter. 

The  so-called  "chronic  ulcer"  of  Robson  has  a  thickened  base, 
and  is  frequently  of  large  size  and  irregular  outline,  in  this  respect 
differing  from  the  chronic  round  and  fissure  ulcer,  in  which  there  is 
but  little  new  tissue  deposit  about  the  ulcer.  Does  the  round  ulcer 
lead  to  the  chronic  cicatricial  ulcer?  It  is  probable  that  the  differ- 
ence is  merely  one  of  degree,  although  the  fact  that  the  latter  is 
much  more  common  in  males  is  rather  against  this  hypothesis. 

The  majority  of  operations  were  for  thick-based  chronic  ulcer 
of  the  stomach  or  its  late  results,  and  these  cases  were  very  satis- 
factory, the  irregular  thickened  patch  of  stomach  or  duodenal  wall 
often  locating  the  process  with  exactitude.  As  a  rule,  the  ulcer 
was  located  near  the  lesser  curvature,  and  not  infrequently  at  the 
pylorus.  The  posterior  wall  was  affected  more  often  than  the 
anterior,  if  only  one  surface  was  involved.  On  the  duodenum  the 
anterior  wall  was  more  often  the  seat  of  ulceration.  The  youngest 
patient  was  a  girl  of  seventeen  and  the  oldest  a  man  of  sixty-four. 
In  60  per  cent,  of  our  malignant  cases  a  previous  history  of  ulcer 
was  obtained.  In  2  cases  malignant  degeneration  of  the  margin 
of  a  chronic  gastric  ulcer  was  demonstrated — certainly  a  strong  ar- 
gument for  the  excision  of  such  ulcers,  when  possible.  We  found 
conditions  favorable  for  excision  of  ulcer  in  only  3  cases.  On  6 
occasions  we  either  excised  or  turned  an  ulcer  in  bv  suture,  in  com- 


184  WILLIAM   J.    MAYO 

bination  with  pyloroplasty  or  gastroduodenostomy.  In  2  of  these 
cases  three-fourths  of  the  pylorus  was  excised  and  closed  by  suture. 

Lund  has  pointed  out  that  "sentinel"  enlarged  lymph-nodes 
in  either  the  lesser  or  greater  omenta  may  aid  the  surgeon  in  locat- 
ing the  ulcer.     We  haA'e  found  this  a  valuable  observation. 

In  all  the  ulcers  of  every  description  which  we  examined  the 
upper  two  inches  of  the  duodenum,  pylorus,  pyloric  antrum,  and 
that  part  of  the  stomach  lying  to  the  right  of  a  line  dra^m  downward 
from  the  esophagus  was  the  seat  of  disease,  and  in  only  a  few  in- 
stances of  extensive  hour-glass  contraction  did  the  ulcer  extend 
to  the  left  of  this  line.  In  handling  the  stomach  during  operation, 
limited  contraction  of  the  wall  could  often  be  noticed  in  the  pyloric 
third,  but  not  toward  the  cardiac  end.  Cannon's  experiments  are 
very  interesting  in  this  respect.  He  demonstrated  with  bismuth 
and  the  a:-ray  that  the  fundus  of  the  stomach  did  not  contract 
strongly,  but  that  the  pyloric  portion,  by  a  backward  action,  kept 
up  a  current  in  the  fundus.  Ulcers  occur  in  all  parts  of  the  stom- 
ach, but  in  the  cardiac  end  it  is  a  question  if  they  are  often  the 
cause  of  chronic  symptoms  calling  for  operation. 

Twelve  chronic  dilatations  without  ulcer  or  obstruction  were 
operated  upon.  In  all  the  cases  the  wall  of  the  stomach  was  of 
normal  or  increased  thickness,  indicating  that  an  obstruction  existed, 
either  from  a  high -lying  but  non-stenosed  pylorus,  or  beyond  the  py- 
lorus. In  1895  I  reported  several  cases  of  interference  with  free 
gastric  drainage  by  valve  formation,  due  to  a  short  gastrohepatic 
omentum  holding  the  pylorus  high,  the  body  of  the  stomach  sagging 
sharply  downward.  More  than  half  of  the  cases  were  of  this  descrip- 
tion. In  a  few  instances  the  medical  diagnosis  was  extreme  atonic 
dilatation;  but  even  in  these  cases  there  was  no  great  thinning  of 
the  gastric  wall.  We  have  not  considered  simple  gastroptosis  suffi- 
cient cause  for  operation,  but  in  a  few  cases  exploration  revealed 
this  condition,  and  in  all  the  cases  the  wall  of  the  stomach  was 
either  of  normal  thickness  or  thinner  than  normal.  In  three  of 
these  cases  shortening  of  the  gastrohepatic  ligament  was  done  after 
the  method  of  Beyea. 

Cancer  of  the  stomach:    109  cases,  17  deaths — 15.6  per  cent. 


Robson. 

Moynihan. 

Mayo. 


Hartmann  Mikulicz 

Fig.  13. — Lines  of  incision  practised  by  different  surgeons  in  the  removal  of  cancer  of  the  stomach. 


OPERATIONS    ri'OV    STOMACH     AM)    DrOOKNI   \I  1  S.> 

Late  diagnosis  and  cachexia  make  the  aspect  of  this  group  dis- 
couraging. Palliative  operations  predominate,  with  considerable 
immediate  mortality  and  no  great  prolongation  of  life.  The  hope 
of  the  future  lies  in  early  exi)l()ralory  incision,  and  the  necessity 
for  this  depends  upon  clinical  ohservation  rather  than  laboratory 
methods,  which  too  often  only  become  valuable  when  the  extent 
of  the  disease  is  beyond  cure.  Given  a  patient  of  middle  or  later 
life,  who  begins  to  lose  flesh  and  appetite  and  suffer  from  indiges- 
tion without  ai)parent  cause,  the  possibility  of  cancer  should  be 
considered;  and  if  the  source  of  the  symptoms  cannot  be  shown 
within  a  few  weeks,  the  situation  should  be  exy)lained  to  the  pa- 
tient, and  the  choice  between  exploration  and  procrastination 
allowed  him.  AVhen  we  consider  that  early  operation  is  the  only 
hope,  we  may  not  wait  on  our  own  responsibility.  The  public  in 
this  way  will  soon  become  educated  and  cures  will  be  more  fre- 
quent. Gastrojejunostomy  for  malignant  disease,  in  our  hands, 
has  had  an  increasing  mortality,  due  to  the  fact  that  the  better 
cases  are  selected  for  gastrectomy,  and  the  late  hopeless  obstruc- 
tions are  given  the  meager  benefits  of  gastro-jejunostomy — 34 
cases,  10  deaths — 30  per  cent. 

Is  there  a  hopeful  outlook  for  cancer  of  the  stomach?  We 
know  of  the  prime  necessity  for  early  operation:  it  now  remains  to 
demonstrate  how  the  procedure  can  be  made  more  effective.  In 
a  general  way,  the  lymphatics  of  the  stomach  lie  in  three  groups: 
First,  the  lesser  curvature  and  lesser  omentum;  second,  along  the 
greater  curvature  and  the  gastrocolic  omentum;  third,  in  thegastro- 
splenic  omentum.  The  main  lymphatic  channels  follow  the  direc- 
tion of  the  blood-vessels  to  the  deep  glands  about  the  celiac  axis. 
The  dome  of  the  stomach,  as  pointed  out  by  Robson,  has  no  main 
lymphatic  channels  and  few  lymphatic  glands.  If  all  the  stomach 
excepting  this  portion  be  excised,  the  remaining  part  will  be  ade- 
quately nourished  on  the  right  side  by  cardiac  branches  derived 
from  the  gastric  artery,  which  joins  the  stomach  at  a  point  from 
one  to  one  and  one-half  inches  below  the  esophagus.  On  the  left, 
the  vasa  brevia,  given  off  from  the  splenic  artery  distal  to  the  origin 
of  the  left  gastro-epiploic  vessel, — a  distance  of  four  and  one-half  to 


186  WILLIAM    J.    MAYO 

eight  inches  from  the  esophagus, — give  an  adequate  blood-supply. 
These  vessels  anastomose  with  the  inferior  phrenic  vessels.  There- 
fore, excision  of  all  the  stomach  lying  below  and  to  the  right  of  a 
line  drawn  between  the  gastric  artery  and  the  left  gastro-epiploic 
vessel  is  the  logical  operation.  The  advantage  of  this  line  of  sec- 
tion is  obvious.  All  the  main  lymphatic  connections  are  removed 
at  the  primary  operation.  We  know  clinically  that  the  remaining 
portion  of  the  stomach  is  seldom  involved  unless  the  primary  lesion 
is  at  the  cardiac  orifice,  and  the  retention  of  the  dome  of  the 
stomach  enables  comparatively  easy  intestinal  anastomosis.  One 
reason  that  only  from  5  to  8  per  cent,  of  gastric  cancers  have  been 
cured  by  extirpation  lies  in  the  fact  that  a  part  of  the  organ  has 
been  retained  in  which  the  vascular  and  lymphatic  connections 
with  the  diseased  area  have  not  only  been  close,  but  direct.  In 
the  dome  of  the  stomach,  the  lymph-current  is  feeble  through  small 
vessels,  and,  most  important  of  all,  is  in  the  other  direction.  IVIiku- 
licz  has  already  called  attention  to  the  necessity  of  removing  the 
whole  of  the  lesser  curvature,  with  its  gastrohepatic  omentum, 
and  has  done  much  to  elucidate  the  question  of  lymphatic  infection 
by  showing  that  in  20  cases  of  gastric  cancer  only  1  was  completely 
free  from  lymphatic  involvement,  although,  in  a  total  of  189  glands 
examined,  110  were  found  to  be  without  contamination.  In 
making  this  radical  operation  we  have  proceeded  as  follows: 

First,  ligate  the  gastrohepatic  omentum  from  the  pylorus  to 
the  gastric  artery,  which  is  tied.  The  section  is  made  as  close  to 
the  liver  as  possible,  and  includes  nearly  the  whole  of  the  lesser 
omentum.  This  mobilizes  the  pyloric  end  of  the  stomach,  which 
is  drawn  down  and  out.  Second,  with  the  fingers  in  the  lesser 
cavity  of  the  peritoneum,  the  gastrocolic  omentum  is  ligated  at  a 
safe  distance.  The  duodenum,  on  the  one  side,  and  the  pylorus, 
on  the  other,  are  doubly  clamped  and  divided  between  with  the 
cautery  knife.  A  purse-string  suture  of  silk  is  placed  around  the 
duodenum,  three-fourths  of  an  inch  below  the  divided  end,  and, 
after  suturing  with  catgut  through  the  cauterized  area,  the  stump 
is  inverted  and  the  purse-string  suture  drawn  tight.  This  disposes 
of  the  duodenum  permanently.     Third,  ligation  of  the  gastrocolic 


Fig.  14. — The  completed  operation  for  cancer  of  the  stomach. 


(M'I:K  AlIONS     ll'ON"    STOMACH      \\l)     IHODKNfM  1  S7 

oiueiiLuin  lo  u  |)<>iiiL  near  Llii^  orij^ln  of  Llic  IcfL  gu.slro-epiploic 
artery,  which  is  lied.  Fourth,  a  groove  is  made  by  heavy  pressure 
forceps,  separating  the  doinc  fiom  the  hahiricc  of  the  sloiiiach, 
and  with  catgut  on  two  needles,  a  shoemaker  stiteh  in  the  i)ressure 
furrow  renders  section  with  the  actual  cautery  bloodless  and 
avoids  opening  the  portion  of  the  stomach  to  be  retained.  This 
line  of  suture  is  turned  in  by  a  continuous  silk  Cushing  suture,  sup- 
ported occasionally  by  an  independent  Ilalsted  stitch  of  the  same 
material.  In  this  step  of  the  operation  we  sometimes  use  the 
Kocher  clamp  and  suture  each  layer  separately.  P'ifth,  gastro- 
jejunostomy between  the  gastric  pouch,  which  is  just  about  large 
enough  for  the  purpose,  and  the  jejunum.  Sixth,  entcro-anas- 
tomosis  between  the  two  limbs  of  jejunum,  short  circuiting  the 
biliary  and  pancreatic  secretions  as  nearly  as  possible  at  the  same 
level  as  the  origin  of  the  jejunum.  It  took  two  deaths  to  teach  us 
the  value  of  this  mana?uver.  The  deaths  were  not  from  regurgi- 
tant vomiting,  but  when  the  anastomosis  was  effected  in  some 
cases,  the  intestine  was  sharply  bent  at  the  site  of  union,  being 
drawn  upward  and  to  the  left  in  such  a  manner  as  to  leave  from 
14  to  16  inches  of  jejunum  hanging  upon  the  anastomosed  area,  a 
situation  in  which  peristalsis  does  not  materially  aid  in  onward 
flow  of  the  biliary  and  pancreatic  secretions.  The  proximal  loop 
becomes  distended  with  these  juices  to  the  level  of  the  anastomosis, 
giving  a  traction  weight  of  a  column  of  fluid  the  diameter  of  the 
distended  intestine.  In  one  patient  on  the  fifth  day  and  one  on  the 
ninth  day  union  suddenly  gave  way  entirely,  or  in  part,  when  the 
patients  were  apparently  doing  well.  This  did  not  happen  in  every 
case — two  out  of  eight  only;  but  in  at  least  half  of  the  cases  the  bad 
mechanics  of  the  situation  was  evident  on  inspection.  Seventh, 
the  remains  of  the  gastrocolic  omentum  are  attached  to  the  poste- 
rior wall  and  the  abdomen  closed.  This  operation  should  give  all 
the  benefits  of  complete  gastrectomy  in  pyloric  cancer.  (I  find 
that  Moynihan  has  recommended  and  practised  a  similar  pro- 
cedure.) 

In  view  of  the  splendid  work  of  Hartmann  and  Cuneo,  it   is 
a  question  whether  the  operation  outlined  should  be  the  routine 


188  WILLIAM   J.    MAYO 

one,  or  for  exceptional  cases  only.  That  the  whole  of  the  lesser 
curvature,  with  the  glands  in  the  corresponding  portion  of  the 
lesser  omentum,  should  be  removed  is  the  copelusion  of  all  surgeons 
of  large  experience;  but  the  advantage  of  removing  the  major 
part  of  the  greater  curvature  is  open  to  debate.  Cuneo  demon- 
strated that  the  lymph-current  along  the  greater  curvature  was 
from  the  left  to  the  right,  and  that  in  pyloric  cancer  not  only 
is  there  comparatively  little  tendency  to  lymphatic  involvement, 
but  that  it  is  confined  to  the  glands  in  the  immediate  vicinity  of  the 
growth,  and  does  not  extend  to  the  left  of  the  pyloric  portion. 
Hartmann,  therefore,  bases  his  line  of  section  upon  this  fact,  and 
removes  all  the  lesser  curvature  and  saves  as  much  as  possible  of 
the  greater  curvature.  We  have  several  times  made  an  operation 
very  similar  to  that  described  by  Hartmann,  as  it  is  certainly  much 
easier  than  the  one  which  we  have  outlined,  and,  as  the  mechanics 
of  the  anastomosis  are  better,  entero-anastomosis  is  unnecessary. 
Occasionally,  however,  growths  or  glands  are  found  to  the  left 
along  the  greater  curvature.  It  may  be  said  that  such  cases  are 
inoperable,  yet  we  have  had  two  such  patients  live  beyond  a  year. 
In  the  8  cases  operated  upon  by  the  radical  method  given  above 
there  were  3  deaths,  while  there  were  but  2  deaths  in  the  18  remain- 
ing cases  operated  by  various  methods  from  simple  pylorectomy 
to  the  operation  of  Hartmann.  The  former  group  comprises  only  a 
small  number  of  the  worst  cases,  and  some  of  the  deaths  might 
have  been  avoided  by  better  technic.  Be  this  as  it  may,  some  form 
of  radical  extirpation  has  been  the  only  reasonably  satisfactory  op- 
eration which  we  have  performed  for  cancer  of  the  stomach :  27 
cases,  5  deaths — 18.5  per  cent.*  One  patient  lived  three  years  and 
seven  months  before  recurrence.  Several  are  alive  and  well  over 
two  years,  and  the  general  average  has  been  over  a  year.  It  is  sur- 
prising how  few  of  those  recovering  from  the  operation  have  failed 
to  live  a  year  or  more. 

It  may  not  be  out  of  place  to  discuss  briefly  the  merits  of  the 

*  Since  completing  this  paper,  one  case  died  after  five  weeks  from  abscess  of 
the  lung,  making  6  deaths — 22.5  per  cent. 


OI'KUATIONS    UPON    STOMACH    AM)    l)\  OUKMM  189 

llirce  chief  inclliods  of  improviiif^  gaslric  drainage,  namely,  py- 
loroplasty, gastro-cnterostoniy,  and  gastroduodenostomy. 

Nineteen  cases  were  subjected  to  tlie  pyloroplasty  of  Ilcineke- 
Miknlicz;  0  of  these  came  to  secondary  gastrojejunostomy  through 
failure  of  the  operation  adequately  to  drain  the  stomach.  The 
remaining  cases  are  well.  There  were  no  deaths.  The  opening 
can  be  made  of  sufficient  size,  but  the  increase  in  caliber  is  not  in 
the  line  of  gravity  drainage,  or,  at  least,  the  enlargement  of  the 
opening  is  as  much  above  the  pylorus  as  below  it,  and  the  greatly 
dilated  stomach,  with  its  overstretched  and  degenerated  muscu- 
lature, is  unable  to  elevate  the  food,  and  the  stagnation  is  not  en- 
tirely relieved.  Again,  in  the  6  reoperated  cases,  the  pylorus  was 
found  adherent  at  a  high  level,  due  to  the  abstinence  of  food  and 
other  causes  of  downward  traction  during  the  healing  process.  In 
3  cases  we  fastened  the  pylorus,  after  plastic  operation,  to  the 
neighborhood  of  the  umbilicus  by  suture,  to  secure  a  low  point. 
These  patients  have  remained  well;  but  as  we  were  also  careful  to 
choose  only  moderate  dilatations,  the  value  of  the  manoeuver  is 
uncertain. 

Gastro-jejunostomy  was  done  168  times,  divided  as  follows: 
Gastrojejunostomy,  ISl;  gastroduodenostomy  after  Finney,  26; 
independent  gastrojejunostomies  in  connection  with  pylorectomy 
and  gastrectomy,  22.  Of  the  121  cases  of  gastrojejunostomy  made 
purely  for  drainage  purposes,  there  were  17  deaths.  The  per- 
centage of  mortality  in  the  benign  cases  was  8  per  cent.;  in  the 
malignant,  30  per  cent.,  the  great  mortality  of  the  latter  being  due 
to  the  choice  of  favorable  cases  for  radical  operation,  the  hope- 
lessly advanced  and  cachectic  coming  to  gastro-jejunostomy,  and, 
could  the  condition  have  been  known  beforehand,  an  operation 
would  not  have  been  undertaken  in  some  of  these  cases. 

Gastrojejunostomy  for  benign  obstruction  at  the  j^ylorus  is 
one  of  the  most  satisfactory  operations  with  which  we  are  ac- 
quainted. It  rapidly  drains  from  the  lowest  point,  and  if  the 
obstruction  at  the  pylorus  is  permanent,  the  new  opening  does 
not  contract  materially.  Again,  if  the  opening  be  made  at  the 
bottom  of  the  stomach  pouch,  at  or  near  the  greater  curvature, 


190  WILLIAM   J.    M^O 

regurgitant  vomiting  will  not  take  place,  and  entero-anastomosis 
is  unnecessary,  providing  either  the  Murphy  button  or  Robson 
bone  bobbin  be  used  mechanically  to  maintain  an  opening  during 
the  early  critical  period.  In  some  instances  a  feeling  of  distention 
or  vomiting  after  operation  may  take  place,  and,  under  such  cir- 
cumstances, we  promptly  direct  gentle  stomach  lavage.  We  now 
use  the  posterior  suture  operation  over  the  bone  bobbin  for  benign 
obstructions,  and  the  Murphy  button  for  malignant  disease,  and 
in  the  latter  instance  the  anterior  method.  However,  as  between 
the  suture  and  the  Murphy  button  and  the  anterior  and  posterior 
operation,  we  have  been  unable  to  see  any  marked  difference  in 
results  beyond  the  occasional  retention  of  the  button  in  the  stom- 
ach, which  seems  to  be  of  no  practical  importance. 

During  the  recent  visit  of  Professor  Mikulicz  to  this  country 
(May,  1903),  he  was  kind  enough  to  do  a  posterior  gastro-jejunos- 
tomy  in  our  clinic  by  a  method  which  I  believe  is  greatly  superior 
to  the  one  we  had  been  in  the  habit  of  doing.  It  avoids  the  possi- 
bility of  angulation,  since  it  does  not  form  a  loop,  with  its  attendant 
dangers.  The  operation,  as  performed,  depends  on  two  simple 
principles:  First,  the  origin  of  the  jejunum  lies  above  the  greater 
curvature  of  the  stomach.  After  opening  the  transverse  mesocolon 
and  fastening  it  to  the  posterior  wall  of  the  stomach,  the  upper 
three  or  four  inches  of  the  jejunum  lie  directly  in  contact  with  the 
gastric  wall,  hanging  perpendicularly  with  its  free  border  (opposite 
the  mesentery),  facing  the  wall  of  the  stomach.  Second,  by  making 
a  transverse  incision  in  the  jejunum  three  or  four  inches  from  its 
origin  and  an  incision  close  to  the  greater  curvature  of  the  stomach, 
a  suture  anastomosis  is  made  in  which  the  stomach  is  drained  at 
the  lowest  point  without  the  possibility  of  kinking  the  intestine. 
The  whole  trouble  has  been  that  in  making  a  longitudinal  incision 
in  the  intestine  it  was  necessary  to  form  the  misfortune-breeding 
loop.  The  scheme  of  the  operation  is  much  the  same  as  that  used 
by  Czerny.  The  good  mechanics  of  the  procedure  has  been  es- 
pecially dwelt  upon  by  Peterson,  of  the  Heidelberg  clinic. 

Gastrojejunostomy,  if  the  pylorus  be  unobstructed,  is  far  from 
satisfactory.     In  a  paper  read  before  the  American  Surgical  Asso- 


OPERATIONS    UPON    STOMACH    AND    DUODENUM  191 

ciulion,  June,  lOO'^,  I  rcporlcd  1  cases  in  which  contraction  at  the 
site  of  the  anastomosis  took  phace,  and  we  have  reoperated  upon  4 
simihir  cases  since  that  time.  In  (5  of  these  cases  we  did  a  secondary 
entero-anastomosis  between  the  hmbs  of  the  loop.  Four  times  the 
entero-anastomosis  was  effected  with  the  Murphy  })utton,  and  two 
of  these  patients  died  from  sudden  separation  of  the  anastomosed 
area  at  the  end  of  the  first  week.  Death  did  not  take  place  in 
two  suture  operations.  In  all  these  cases  the  proximal  limb  of 
jejunum  from  the  point  of  anastomosis  to  its  origin  looked  enlarged 
and  thickened,  a  condition  that  might  be  called  water-logged,  and 
in  marked  contrast  to  the  bowel  immediately  distal  to  the  anas- 
tomosis. In  this  condition  of  the  afferent  loop  lay  the  reason  for 
the  failure  of  the  plastic  union  after  the  button,  and  merely  illus- 
trates the  well-known  danger  of  setting  up  pressure  necrosis  in 
damaged  tissues.  Primary  entero-anastomosis  with  the  button 
is  safe,  but  not  so  secondary  operations.  If  the  obstruction  at  the 
pylorus  is  com})lete,  this  condition  of  the  jejunum  above  the  gastro- 
intestinal anastomosis  is  not  found.  A  large  number  of  cases  of 
benign  affections  of  the  stomach  without  pyloric  stenosis  require 
operation.  This  is  particularly  true  in  ulcer,  and  relapse  after  this 
operation  has  been  frequent.  Our  observations  would  seem  to 
show  the  following  course  of  events.  After  the  operation  there 
is  at  least  temporary  healing  of  the  ulcer.  The  pylorus  begins 
to  functionate  normally,  and  the  unnecessary  gastro-intestinal 
fistula  contracts.  There  is  renewed  irritation  from  retained  se- 
cretions, followed  by  reopening  of  the  ulcer,  return  of  pyloric 
spasm,  and  failure  of  the  operation  to  effect  a  permanent  cure. 
In  some  cases  the  double  stomach  drainage  seems  to  give  rise  to 
unpleasant  symptoms  without  contraction  of  the  fistula.  In  28 
cases  of  gastrojejunostomy  with  open  pylorus,  8  came  to  secondary 
operation  from  contraction  of  the  gastro-intestinal  opening,  while 
in  all  cases  with  permanent  ol>struction  at  the  pylorus  there  were 
no  cases  of  secondary  operation  from  this  cause.  This  has  also 
been  the  experience  of  Ochsner,  who  points  out  the  fact  that  if  re- 
lapse takes  place,  symptoms  will  arise  within  four  months.  To 
obviate  this  sequela,  in  one  case,  at  the  primary  o|)eration,  we 


192  WILLIAM    J.    MAYO 

divided  the  pylorus  and  closed  both  the  gastric  and  duodenal  ends 
by  suture,  thus  creating  the  favorable  condition  of  complete  ob- 
struction. Once  we  sutured  the  pylorus  high  up  under  the  liver, 
causing  valve  formation,  as  first  suggested  by  Cordier.  Once  we 
placed  a  circular  purse-string  suture  about  the  pylorus,  closing 
sufficiently  tight  to  obstruct  the  opening.  This  idea  was  adopted 
from  Dawbarn.  I  may  say  that  all  of  the  methods  proved  satis- 
factory; but  there  was  the  grave  objection  of  too  much  operating 
for  a  benign  condition,  and  it  introduced  unnecessary  elements  of 
danger.  In  June,  1902,  Finney  introduced  his  method  of  so-called 
pyloroplasty,  but  which  is  in  reality  a  gastroduodenostomy.  The 
opening  is  downward  in  the  line  of  gravity,  and  in  most  of  the  suit- 
able cases  for  this  operation  the  gastric  dilatation  is  not  extreme. 
In  two  cases  of  rather  extensive  dilatation  and  pouching  we  com- 
bined with  it  shortening  of  the  gastrohepatic  ligament,  as  described 
by  Beyea.  The  operation  of  Finney  is  especially  adapted  to  those 
cases  in  which  there  is  little  disease  about  the  pylorus.  It  enables 
careful  examination  of  the  pyloric  end  of  the  stomach,  and  excision 
of  a  neighboring  ulcer  can  be  easily  combined  with  it.  We  had 
two  such  cases.  It  is  less  suitable  if  there  be  extensive  involve- 
ment of  the  pylorus;  but  it  is  in  just  this  class  of  cases  that  gastro- 
jejunostomy is  at  its  best.  The  question  to  be  settled  by  further 
experience  is,  whether  the  operation  of  Finney  will  as  rapidly  cure 
active  ulcer  of  the  stomach  as  gastrojejunostomy.  In  the  latter 
operation  the  drainage  is  from  the  cardiac  end  to  the  left  of  the 
muscular  pyloric  portion;  while  even  if  the  pylorus  be  made  of 
ample  size  by  the  Finney  procedure,  the  food  and  secretions  must 
pass  the  ulcer  site  before  it  leaves  the  stomach,  and  we  know  that 
obstructions  are  not  at  all  necessary  to  the  formation  of  ulcer,  as 
they  exist  beyond  the  pylorus  in  the  duodenum.  In  26  cases  oper- 
ated upon  by  the  method  of  Finney  we  had  one  death,  and  that 
from  avoidable  cause.  Were  it  not  for  the  mortality,  resection  of 
the  muscular  pyloric  portion  of  the  stomach  would  be  indicated  in 
gastric  ulcer,  as  in  this  way  the  ulcer-bearing  area  would  be  per- 
manently disposed  of  and  an  absolute  cure  insured.     This  pro- 


(Jl'KUATIONS    t   |•(^^    STOMACH    AM)    DCODENUM 


D.'J 


<'('(lun'  was  firsl   .siiH<r<vst<'(l  hy   Ilodman,  and    1   Ix-licNC,  with   liiui, 
thai   it  will  l)c  the  operation  of  tin-  near  I'litiirc. 


A  TABLE  OF  ;?1.'5  OI'KIJATIONS  II'OX  TIIK  STOMACfl  AM)  IlkST 
I'OUTIOX  OF  THH  1)1  ODK.Nl M 

St(jma(|[ 
Benicm  Total  Recovered  Died 

(iiistrojcjiinostomy 89  82  7 

(iiistrodiiodciio.sloiny 28  27  1 

Fyloropla.sly 19  19 

(ia.slro.slomy •.  .      4  4 

(iaslrotomy 5  5 

Fxcisioii  of  iilctM' 3  3 

I'crfuialiii'i  iiltrr 2  1  1 

(lun.sliot 1  1 

(la.strorrliapliy 1  1 

(la.stroplicalion 1  1 

Ilour-gla.s.s  .stomach 3  2  1 

A(!lu'.sion.s 8  8 

Sliortening  of  ga.strohepatic  ligament  (Beyea)  ...     6 

Sutxliaphragmatic  abscess  from  gastric  ulcer.  ...      2  1  1 

Fistula  of  stomach  and  gall-l)ladder 1  1 

173  156  11 


Cancer  Total 

(iastrectomy  and  pylorectomy 27 

(lastro-enterostomy 34 

(lastrostomy 13 

Exploratory 38 

112 


dvered 

Died 

22 

G 

24 

10 

11 

2 

38 

95 


18 


First  Portion  of  Duodenum 
Total 

Excision  of  ulcer 3 

Perforating,  acute 1 

Perforating,  chronic 2 

Clironic  ulcer 6 

I'lcer  of  both  duodenum  and  stomach 5 

Anastomosis  Ijetween  the  first  and  second  por- 
tion of  duodemmi  for  ulcer 1 

Adhesions,  result  of  periduodenitis 4 

Adhesions,    result   of  inflammation  of  accessory 

lol)e  of  pancreas 1 

Fistula  between  gall-bladder  and  duodenum  re- 
quiring suture 5 

28 


Recovered 
2 
1 
2 
5 
3 

1 
4 

1 

5 

26 


Died 
1 


VOL.  1 — 13 


CHRONIC    ULCER    OF    THE    STOMACH    AND 

DUODENUM  FROM  A  SURGICAL 

STANDPOINT* 

WILLIAM   J.    MAYO 


The  stomach  is  a  fuel  storehouse  into  which  is  placed  at  inter- 
vals a  quantity  of  material  for  the  slower  process  of  digestion. 
Its  function  is  to  equalize  the  temperature  of  the  ingesta  and,  by 
means  of  a  weak  solution  of  hydrochloric  acid  and  pepsin,  to 
macerate  and  break  up  the  food-masses.  The  resulting  product 
is  slowly  delivered  into  the  small  intestine,  where  digestion  is 
completed  and  assimilation  accomplished.  Little  absorption 
takes  place  in  the  stomach.  The  first  portion  of  the  duodenum 
can  be  said  to  be  the  vestibule  of  the  small  intestine,  and  related 
most  closely  to  the  stomach,  the  common  duct  properly  marking 
the  beginning  of  the  small  intestine.  Its  internal  diseases  are 
closely  associated  with  those  of  the  stomach,  and  usually  due  to 
the  same  causes. 

This  portion  of  the  duodenum  is  often  affected  externally 
by  diseases  of  the  gall-bladder.  It  acts  as  a  buffer  between  the 
secretions  of  the  liver,  the  pancreas,  and  the  stomach,  and,  because 
of  its  situation,  the  upper  four  inches  of  the  duodenum  is  the  most 
frequently  diseased  part  of  the  alimentary  tract  of  the  same 
length. 

The  functions  of  the  stomach  are  thus  closely  divided  into  two 
groups, — the  mechanical  and  the  chemical, — and  experience 
teaches  that  the  mechanics  are  of  far  greater  importance  than  the 
chemics.     The    stomach  does  not  empty  itself  by  gravity,  but 

*  Read  before  the  Ramsey  County  Medical  Society  October  26, 1903.  Reprinted 
from  "The  St.  Paul  Medical  Journal,"  February,  1904. 

194 


C  IlHONir    ri.CKK    OF    STOMACH    AND    DUODENUM  195 

hy  muscular  acliou,  and  lliis  activity  is  of  a  peculiar  sort.  The 
fundus  contracts  slowly,  forcing  the  contents,  as  a  whole,  toward 
(lie  jnloric  end.  The  pyloric  portion,  /,  r.,  that  [jart  of  the 
stomach  lying  to  the  right  of  the  esophagus  and  having  the  lesser 
curvature  as  its  .suiierior  wall,  is  the  mill,  grinding  and  pulverizing 
the  food.  From  the  right  side  the  pylorus  is  turning  the  product 
into  the  duodenum,  as  demonstrated  by  Cannon  in  his  bismuth 
and  j:-ray  experiments.  We  have  seen  this  pyloric  contraction 
take  place  many  times  at  the  operating  table;  ring-like  constric- 
tions appear  and  disappear,  and,  again,  limited  contractions  of 
the  gastric  wall  are  to  be  seen,  which  subside  quickly.  Sometimes 
a  vermicular  action  of  this  entire  end  of  the  stomach  is  apparent. 
The  pylorus  itself  is  but  a  small  increase  of  the  circular  fibers, 
about  one-half  the  size  and  power  of  the  external  sphincter  ani. 
I  am  satisfied  that  the  so-called  pyloric  spasm  does  not  refer  to 
the  pylorus  alone,  but  that  the  contracture  may  involve  any  part 
or  all  of  the  pyloric  end  of  the  stomach. 

It  would  not  be  within  the  limits  of  this  paper  to  go  into  the 
etiology  of  gastric  ulcer,  but  two  facts  are  preeminent:  first, 
that  75  per  cent,  of  gastric  ulcers  lie  in  the  grinding  apparatus  of 
the  pyloric  end,  that  is,  in  the  area  exposed  to  mechanical  injury, 
and,  second,  that  at  some  time  in  the  history  of  gastric  ulcer  and 
in  the  majority  of  cases,  at  all  times,  there  is  a  relative  increase 
in  the  secretion  of  hj'drochloric  acid,  and  whether  cause  or  effect, 
this  excess  is  a  most  important  etiologic  factor.  This  is  shown 
by  the  frequency  of  typical  peptic  ulcer  in  the  first  portion  of  the 
duodenum  above  the  common  duct  with  its  alkaline  fluids,  and 
by  the  occasional  appearance  of  secondary  ulcer  in  the  jejunum, 
which  has  resulted  in  a  few'  cases  after  the  performance  of  gastro- 
enterostomy to  divert  the  food-current  from  the  ulcerated  area. 

There  is  hardly  a  question  connected  with  ulcer  of  the  stom- 
ach which  is  not  in  dispute.  The  many  hypotheses  prove  the 
paucity  of  facts.  Of  statistics,  there  are  more  than  enough,  but 
their  divergence  renders  them  confusing.  In  some  countries 
ulcer  is  said  to  be  very  frequent,  as  in  certain  parts  of  Germany — 
given  as  high  as  10  per  cent. ;  but  whether  based  on  the  notoriously 


196  WILLIAM   J.    MAYO 

defective  clinical  data  or  upon  postmortem  evidence  is  not  devel- 
oped. Stark,  in  Copenhagen,  found  13  per  cent,  in  the  autopsy 
findings;  Greiss,  in  Kiel,  8.3  per  cent.;  Brinton,  of  Philadelphia, 
5  per  cent.;  Berthold,  at  the  Berlin  Charite,  2.7  per  cent.  The 
relative  freciuency  in  the  sexes  ranges  from  the  statistics  of  Fiedler, 
who  in  2200  autopsies  found  20  per  cent,  of  the  female  subjects 
with  evidence  of  recent  or  old  ulcer,  and  only  1.5  per  cent,  of  the 
male  subjects.  In  793  ulcers  (postmortem)  Welch  found  60  per 
cent,  in  women  and  40  per  cent,  in  men.  In  262  cases  Berthold 
found  134  in  women  and  128  in  men.  At  the  operating  table 
we  found  59  per  cent,  women  and  41  per  cent.  men.  In  our 
experience  the  large  irregular  ulcer  is  more  common  in  adult  males, 
and  this  has  been  the  general  observation.  In  100  cases  of  chronic 
ulcer  tabulated  by  Taylor,  72  were  males  and  28  females.  On 
the  contrary,  the  small  ulcer  has  been  more  common  in  the  female. 
The  increased  percentage  in  women  is  due  to  the  fact  that  acute 
forms  of  round  ulcer  are  most  frequent  in  young  females  of  the 
chlorotic  type.  In  a  considerable  proportion  of  cases — about  20 
per  cent. — more  than  one  ulcer  is  present,  a  frequent  combination 
being  one  on  the  anterior  and  one  opposite  on  the  posterior  wall, 
or  one  or  more  ulcers  on  the  stomach  and  one  of  the  duodenum. 

In  463  cases  Brinton  found  57  cases  with  2  ulcers,  16  cases 
with  3  or  4,  2  cases  with  5,  and  4  cases  with  more  than  5.  Osier 
reports  1  case  with  35  ulcers.  At  least  75  per  cent,  of  all  cases  of 
gastric  ulcer  are  to  be  found  in  the  pyloric  portion  of  the  stomach, 
and  in  an  increasing  ratio  toward  the  pylorus  and  lesser  curva- 
ture. In  793  cases  Welch  found  235  posterior,  288  lesser  curva- 
ture, 96  anterior  wall,  95  in  the  pyloric  ring,  29  in  the  fundus,  and 
27  along  the  greater  curvature. 

In  our  series  of  gastric  and  duodenal  ulcer,  11  per  cent,  were 
located  in  the  first  portion  of  the  duodenum.  Adult  males  are 
most  frequently  the  subject  of  chronic  ulcer  of  the  duodenum. 
In  24  cases  which  came  to  operation  in  our  experience  20  were 
males. 

Gastric  and  duodenal  ulcers  can  be  divided  into  four  groups: 
First,  mucous  erosions  involving  the  superficial  epithelial  portion 


CIIUOMC    LLCEH    OK    STOMA*  II    AM)    DlOl^KMM  1  !>7 

of  tlio  mucous  nuMubraiie  only;  socoikI,  roinid  ami  (issun-  ulcers, 
which  ponclrafc  thn)U<fh  to  the  sul)inucous  coat,  but  do  not  in- 
volve the  luuscular  ami  peritoneal  coverings  except  in  perforative 
cases;  third,  chronic  irregular  ulcer,  which  involves  all  the  coats, 
and  usually  shows  evidence  of  cicatrization  in  some  part  of  its 
extent,  and,  fourth,  benign  obstructions  of  inflammatory  origin. 
This  last  group  is  based  upon  a  complication,  but  cannot  always 
be  clearly  traced  to  the  known  varieties  of  ulcer  already  classified. 
Deaths  from  perforation  and  hemorrhage  have  permitted 
exhaustive  examination  as  to  the  nature  and  character  of  acute 
ulcer,  and,  as  a  result,  we  have  fairly  accurate  methods  of  diagnosis. 
The  vomiting,  hemorrhage,  local  tenderness,  pain,  and  hyper- 
chlorhydria  form  a  classic  group  of  symptoms.  Chronic  ulcer, 
unfortunately,  cannot  be  clearly  predicted  upon  these  symptoms, 
and  this  is  perhaps  the  most  unfortunate  feature  of  the  subject. 
Acute  perforation  and  fatal  hemorrhage  are  not  common  in 
chronic  ulcer,  and  vomiting  is  by  no  means  of  frequent  occurrence 
unless  obstruction  supervenes.  The  chronic  ulcer  must  not, 
therefore,  be  confused  with  the  acute  form,  although  during  an 
exacerbation  there  may  be  some  of  the  symptoms  of  acute  ulcer. 
The  clinical  picture  presented  by  chronic  ulcer  varies  widely. 
The  most  prominent  symptom  is  pain — painful  digestion.  Some- 
times the  pain  is  of  a  burning  character;  in  other  cases  it  is  de- 
scribed as  a  boring  pain.  There  is  more  or  less  tenderness  at  the 
epigastrium,  but  not  often  the  t\'])ical  pain  pressure-points  front 
and  back,  which  are  found  in  acute  ulcer.  Usually  the  pain  is 
more  severe  after  eating,  but  sometimes  taking  food  relieves  the 
distress  for  a  time,  probably  by  diluting  the  irritating  gastric 
secretions.  The  painful  "spells"  usually  last  intermittently  for 
some  (lays  or  weeks,  to  be  followed  by  an  interval  of  comparative 
health,  lasting  some  weeks  or  months.  These  health  periods  are 
very  confusing,  and  often  lead  to  erroneous  belief  as  to  cure. 
The  pain  is  not  constant,  and  does  not  attend  each  meal.  At  one 
time  great  pain  will  follow  a  light  meal,  and  again  a  hearty  meal 
will  bring  no  complaint.  Unless  there  is  obstruction,  vomiting 
is  rare,  the  pain  causing  the  victim  to  reduce  his  diet,  often  to 


198  WILLIAM   J.    aiAYO 

semi-starvation,  having  learned  that  this  will  most  quickly  relieve 
the  distress.  Gerhardt  says  that  "the  ulcer  patient  has  appetite, 
but  is  afraid  to  eat,  while  the  victim  of  cancer  has  but  little  desire 
for  food."  Hemorrhage  in  appreciable  quantities  is  rare.  In 
the  anemic  forms  there  is  probably  a  pretty  continuous  loss  of 
blood,  but  not  often  vomited  or  detected  in  the  stools.  Con- 
stipation is  the  rule,  but  in  some  cases  the  opposite  is  true,  for  it 
must  be  borne  in  mind  that  digestion,  or  at  least  gastric  motility, 
is  increased  in  many  cases  of  irritable  ulcer,  and  the  food  is  hurried 
into  the  duodenum  even  more  rapidly  than  normal.  At  the  height 
of  an  attack  of  pain  food  can  seldom  be  withdrawm  from  the 
stomach  by  the  tube.  The  stomach  is  not  sensitive  to  touch, 
as  shown  during  operation  with  local  anesthesia,  but  gas  disten- 
tion causes  great  distress,  and  this  gaseous  pressure  after  taking 
food  is  in  itself  a  valuable  diagnostic  sign.  It  is  rarely  absent 
during  the  height  of  the  pain.  The  symptoms  of  duodenal  ulcer 
are  much  the  same  as  ulcer  of  the  stomach;  the  attacks  of  pain 
are  even  more  severe,  and  may  resemble  gall-stone  colic,  the  pain 
and  tenderness  being  in  the  region  of  the  gall-bladder.  In  three 
of  our  cases  the  operation  was  performed  with  the  expectation 
of  finding  biliary  calculi.  A  great  deal  has  been  written  about  the 
possibility  of  locating  the  situation  of  the  ulcer  by  the  length  of 
time  after  taking  food  before  the  pain  appears.  In  a  general  way 
it  is  true  that  the  ulcer  in  the  vicinity  of  the  pylorus,  and  especially 
in  the  duodenum,  does  not  develop  pain  as  quickly  after  eating  as 
in  the  body  of  the  stomach;  but  little  reliance  can  be  placed  upon 
this  sign,  first,  because  of  the  great  frequency  of  symptom-produc- 
ing ulcer  near  the  pylorus,  while  ulcers  at  the  fundus  are  more 
often  latent,  and,  second,  because  of  the  fact  that  in  a  considerable 
percentage  of  the  cases  the  lesions  are  multiple.  There  is  a  general 
tendency  to  believe  that  all  palpable  tumors  of  the  stomach  are 
malignant,  and  this  has  often  led  to  death  from  starvation,  a 
benign  tumor  with  a  fatal  stenosis  being  supposed  to  be  malig- 
nant and  necessarily  hopeless.  We  have  seen  6  well-defined 
tumefactions  due  to  the  thickening  about  a  chronic  ulcer.  Rein- 
hardt  found  16  cases  of  simple  ulcer  giving  rise  to  a  tumor.     Gas- 


CHRONIC    ULCER    OF    STOMAfU    AM>    DUODENUM  190 

trie  toluiiy  is  a  .somcwliat  rare  condition,  wliidi,  however,  exists 
in  a  lar^aT  proportion  of  cases  than  has  been  supposed.  Heretofore, 
only  tlie  more  severe  grades  have  been  diagnosed,  and  the  larger 
percentage  of  these  cases  have  died.  Frankl-IIochwart  found  10 
deaths  out  of  11  cases,  and  Albu  found  31  out  of  40.  There  are 
many  mild  cases  in  connection  Avitii  the  more  .severe  grades  of 
gastric  dihitation  siiown  by  muscular  cramps,  prickling  in  the 
extremities,  but  without  typical  contractions,  and  these  .symptoms 
should  call  attention  to  the  necessity  of  immediate  operation  for 
drainage  purposes.  Of  laboratory  methods  of  diagnosis,  excess 
of  hydrochloric  acid  is  one  which  has  proved  to  be  of  value,  and 
this  only  as  corroboratory  evidence. 

So  much  for  chronic  ulcer  without  complications.  The  large 
majority  of  cases  develop  changes  in  the  size  or  position  of  the 
stomach  as  the  result  of  complicating  cicatrices,  adhesions,  or 
obstructions.  In  fact,  many  cases  do  not  have  symptoms  upon 
which  a  diagnosis  can  be  based  before  the  development  of  these 
changes.  Of  all  these  conditions,  narrowing  or  fixation  of  the 
pylorus  is  the  most  important.  An  ulcer  in  the  vicinity  of  the 
pylorus,  by  contraction  or  spasm,  may  mechanically  obstruct  the 
progress  of  the  food,  with  resulting  dilatation  of  the  stomach. 
This  produces  the  so-called  pyloric  syndrome  of  Hartmann, 
pain,  indigestion,  gas,  and  hypersecretion,  and  in  many  cases  per- 
istaltic waves  can  be  seen  passing  from  left  to  right  over  the  gas- 
tric area.  With  a  stomach-tube  and  an  ordinary  Davidson  syr- 
inge the  stomach  can  be  dilated.  If  the  lesser  curvature  is  in 
its  proper  position  and  the  great  curvature  lies  below  the  umbilicus, 
some  degree  of  dilatation  is  present.  If  the  entire  stomach  is  pro- 
lapsed, the  question  of  dilatation  is  easily  ascertained  by  noting 
the  relative  position  of  the  curvatures  on  air  distention.  Pyloric 
obstruction  gives  unmistakable  evidence  of  its  presence,  dilatation, 
stagnation,  and  retention  of  food  causing  fermentation,  late  vomit- 
ing, and  emaciation.  These  cases  are  seen  in  all  stages  from  the 
slight  temporary  interference  with  digestion  to  the  most  marked 
degree  of  disability.  The  condition  can  be  aptly  compared  to  a 
valvular  heart  lesion.     Spells  of  dilatation  alternating  with  com- 


200  WILLIAM   J.    :\L\YO 

pensation  through  hypertrophy  give  periods  of  comparative 
health  after  a  more  or  less  prolonged  term  of  gastric  insufficiency. 

The  best  practical  test  as  to  the  loss  of  motility  is  the  finding 
of  remnants  of  food  in  the  stomach  upon  using  the  tube  before 
breakfast.  The  various  test-meals  have  some  corroboratory 
value.  Of  over  1200  cases  in  which  careful  examination  of  the 
stomach-contents,  including  test-breakfast  and  so  forth,  was  made, 
nearly  400  came  to  operation.  The  clinical  diagnosis,  based  on 
the  history,  physical  examination  of  the  stomach,  with  the  use 
of  the  stomach-tube  to  develop  the  outlines  and  remove  reten- 
tion products,  gave  a  correct  diagnosis  in  the  large  majority  of 
cases.  The  chemical  and  microscopic  examination  of  the  gas- 
tric contents  proved  of  little  value.  The  only  one  upon  which 
any  reliance  is  to  be  placed  is  that  high  values  for  hydrochloric 
acid  argue  for  ulcer  and  low  values  for  cancer;  but  only  as  cor- 
roboratory evidence,  since  the  exact  opposite  may  be  true.  With- 
out going  into  the  question  of  differential  diagnosis,  I  wish  to 
call  the  attention  of  the  general  practitioner  to  the  fact  that 
refinements  of  technical  diagnosis  are  often  useless,  and  occasion- 
ally harmful,  in  causing  delay,  and  that  the  sensible  practitioner 
with  the  few  simple  means  at  his  command  is  perfectly  capable 
of  arriving  at  a  reasonable  diagnosis,  and  will  at  least  be  able  to 
direct  the  majority  of  his  patients  needing  surgical  treatment 
to  the  surgeon  in  time  to  be  benefited. 

The  prognosis  of  ulcer  of  the  stomach  has  given  rise  to  much 
discussion.  Tricomi  believes  that  20  to  25  per  cent,  will  die  under 
medical  treatment.  Brinton  estimates  that  about  50  per  cent, 
are  cured  by  medical  means.  Debove  and  Remond  state  that 
25  per  cent,  die  directly  from  the  lesion  itself  (perforation  and 
hemorrhage),  and  25  per  cent,  additional  from  different  compli- 
cations, such  as  pulmonary  tuberculosis  due  to  the  chronic  anemia. 
Leube,  who  has  given  the  subject  of  gastric  ulcer  careful  study, 
says  that  25  per  cent,  die  from  the  direct  effect  of  the  lesion,  and  that 
cases  curable  medically  should  be  cured  in  four  to  five  weeks'  time. 
A  recent  study  of  500  patients  treated  at  the  London  Hospital 
between  1897  and  1902  is  most  interesting:    211  had  had  attacks 


CIIHONIC    !!.(  KR    or    ST().MA(  II    AM)    DUODENUM  201 

prcN  ioiisly,  that  is,  were  known  to  have  had  ulcer  with  intervals 
ol"  ai)i)areiil  enre,  18  per  cent,  died,  and  4£  per  cent,  were  not 
cured  at  the  time  of  discharge.  A  total  of  GO  per  cent,  died  or 
were  not  cured.  EHniinate  chronic  gastric  ulcer,  and  the  cases 
ol"  chronic  dyspepsia,  gastralgia,  and  cardialgia,  not  due  to  gall- 
stones or  the  appendix,  will  be  reduced  to  small  proportions. 
The  development  of  cancer  upon  chronic  ulcer  is  also  a  risk,  the 
full  significance  of  which  has  only  of  late  become  apparent.  Du- 
plant  has  been  (juoted  as  against  the  theory  of  cancer  formation 
after  ulcer;  but  Audisten,  in  going  over  practically  the  same 
material  recently,  has  shown  that  pyloric  cancer  often  begins 
at  the  margin  of  an  ulcer.  Lebert  says  that  9  per  cent,  only  become 
cancerous;  but  this  refers  to  those  cases  which  pass  directly 
from  the  one  condition  into  the  other.  How  about  the  early 
ulcers  followed  in  later  years  by  malignant  change?  Statistics 
upon  this  point  are  not  available,  but  most  observers  place  cancer- 
grafting  upon  ulcer  base  much  higher.  In  135  cases  Graham 
found  a  good  ulcer  history  preceding  cancer  in  60  per  cent,  of 
cases;  but  in  many  cases  years  had  elapsed  between  the  ulcer 
and  the  cancer.  From  the  standpoint  of  a  pathologist,  FUtterer 
comes  out  very  strongly  for  the  cancer  upon  ulcer  theory,  and 
especially  as  secondary  to  the  so-called  "fish-hook"  ulcer.  Dunn 
says  that,  reasoning  from  analogy  alone,  one  must  conclude  that 
ulcer  is  a  frequent  precancerous  condition,  and  he  believes  that 
this  can  be  demonstrated  from  his  own  experience.  We  have 
specimens  showing  the  two  conditions  existing  in  the  same  case- 
Cases  with  early  history'  of  ulcer,  which  develop  decided  gastric 
symptoms  later,  should  be  looked  upon  as  suspicious  of  malignant 
disease. 

Before  taking  up  the  discussion  of  the  surgical  treatment,  let 
me  add  a  few  words  in  regard  to  some  dilatations  of  the  stomach 
not  of  organic  origin,  such  as  the  so-called  atonic  dilatations  often 
found  in  neurasthenic  individuals,  and  without  the  pyloric  syndrome 
of  Ilartmann.  In  these  cases  there  is  no  retention  and  little 
stagnation  of  food.  As  a  rule,  these  patients  are  not  benefited  by 
operation.     This  is  also  true  of  gastroptosis,  which  we  have  founti 


202  WILLIAM   J.    MAYO 

to  be  present  in  over  half  of  the  cases  of  movable  kidney.  Re- 
laxed conditions  in  the  neurasthenic  state  are  not  often  perma- 
nently benefited  by  surgical  operation.  It  is  one  of  the  misfor- 
tunes of  surgical  progress  that  neurasthenic  symptoms  are  too 
often  mistaken  for  organic  disease. 

Uncertainty  of  diagnosis  will  render  the  majority  of  opera- 
tions primarily  an  exploration,  either  as  to  the  actual  condition 
present  or  as  to  its  extent  and  surgical  indications. 

The  incision  is  placed  in  the  median  line,  between  the  ensi- 
form  cartilage  and  the  umbilicus.  This  enables  the  movable  por- 
tion of  the  stomach  to  be  drawn  out  of  the  abdomen.  The  exami- 
nation should  be  thorough,  and  should  include  a  digital  explor- 
ation of  the  fundus  and  the  cardiac  orifice  in  every  case,  to  avoid 
overlooking  high  hour-glass  contractions.  The  duodenum  should 
be  inspected  and  palpated  in  its  upper  four  inches,  and  the  gall- 
bladder should  also  be  examined,  as  complicating  stones  are  not 
infrequent.  If  one  ulcer  is  found,  search  should  be  instituted  for 
others.  Usually  even-  small  ulcers  can  be  located  by  a  slight 
thickening  of  the  gastric  wall,  perhaps  a  little  place  where  the 
mucous  coat  is  glued  to  the  muscular  tunic,  preventing  the  normal 
sliding  of  one  upon  the  other.  Ulcers  involving  the  muscular 
and  peritoneal  coats  are  easily  recognizable  by  the  milky  or  opaque 
appearance  of  the  peritoneum,  usually  smooth  and  having  the 
thick,  stiff  feel  of  scar  tissue,  with  lessened  vascularity,  unlike 
the  nodular  "feel"  of  gastric  cancer.  Lund  has  pointed  out 
that  enlarged  glands  in  the  omenta  may  aid  localization,  and  we 
have  found  this  sign  of  great  value.  Strange  to  say,  such  lymph- 
nodes  are  most  usually  located  in  the  gastrocolic  omentum,  rather 
than  in  the  lesser  omentum,  a  situation  so  peculiar  to  cancer. 
To  locate  ulcers  on  the  posterior  wall  it  may  be  necessary  to  open 
the  lesser  cavity  of  the  peritoneum  suiBficiently  to  introduce  a 
finger  for  exploration.  This  can  be  done  either  through  the  lesser 
or  the  gastrocolic  omentum. 

Exploration  of  the  gastric  cavity  can  be  best  accomphshed 
by  a  longitudinal  incision  into  the  stomach,  half  way  between  the 
curvatures.     Through  this  opening  a  short  wide  speculum  can 


CIIRO.VK'    VLCFM    OK    STfXMACII    AM)    DTODKNUM  203 

lie  inlroducvd,  and,  with  u  fiiif^ci-  heliiiid.  Llic  greaLcr  part  of  the 
niucous  membrane  can  he  gone  over.  Small  ulcers  may  be  diffi- 
cult to  locate,  and  in  many  cases  prolonged  search  for  an  ulcer, 
the  medical  diagnosis  of  which  is  established  beyond  (jucstion, 
is  not  advisable.  On  one  occasion  a  thorough  exploration  did  not 
reveal  an  ulcer  which  had  bled  repeatedly  for  weeks,  and  it  wa.s 
only  by  accident  that  sponging  the  mucous  surface  started  up 
the  hemorrhage  from  a  little  fissure  previously  undetected. 

The  indication  for  the  surgical  treatment  of  gastric  ulcer 
is  of  a  two-fold  nature:  first,  the  question  of  the  ulcer  itself,  and, 
second,  the  relief  of  the  comphcating  dilatation,  distortion,  ad- 
hesions, etc.  The  keynote  in  the  treatment  is  drainage,  because 
it  is  largely  a  question  of  mechanics.  In  some  cases  the  ulcer- 
ation has  already  terminated,  and  the  problem  to  be  solved  is 
purely  mechanical.  Gastro-enterostomy  is  the  operation  of  the 
widest  range  of  application,  but  excision  of  the  ulcer,  pylorectomy, 
and  pyloroplasty  have  each  a  limited  field  of  usefulness;  w^hile  in 
hour-glass  contractions  gastrogastrostomy  combined  with  gas- 
tro-enterostomy is  necessary  to  -establish  a  cure. 

Excision  of  the  ulcer  would  appear  to  be  the  indicated  pro- 
cedure; yet  this  has  some  disadvantages.  In  the  first  place,  in 
a  considerable  percentage  of  cases  there  is  more  than  one  ulcer 
present,  and  one  or  more  may  be  undetected  or  exist  in  an  inac- 
cessible situation.  Again,  the  tendency  to  ulceration  exists,  and 
new  ulcers  may  manifest  themselves  later.  There  is  also  the 
liability  of  future  contraction,  the  bands  having  their  origin  at 
the  site  of  a  former  ulcer.  It  is  probable  that  the  radical  pro- 
cedure of  Rodman  will  be  indicated  in  an  increasing  number  of 
cases.  He  advises  complete  excision  of  the  ulcer-bearing  area, 
that  is,  the  muscular  pyloric  region,  to  be  followed  by  independent 
gastrojejunostomy.  This  procedure  would  meet  all  the  indica- 
tions, and  also  prevent  a  possible  malignant  degeneration  of  the 
ulcer  base. 

Pyloroplasty  has  a  small  field  of  usefulness  in  narrow  stric- 
tures of  the  pylorus,  provided  the  ulcer  has  healed.  The  objec- 
tions to  it  are  that  there  is  great  liability  to  fixation  of  the  pylorus 


204  WILLIAM   J.    MAYO 

after  operation,  and  also  a  tendency  to  recontraction.  However, 
it  is  a  safe  operation;  in  19  cases  we  had  no  deaths,  but  we  had 
to  reoperate  upon  6  cases. 

The  gastroduodenostomy  of  Finney  is  a  far  better  procedure. 
It  gives  a  very  large  opening,  and  as  the  enlargement  is  down- 
ward in  the  line  of  gravity  drainage,  the  results  are  much  better 
than  in  the  unmodified  pyloroplasty.  We  have  made  this  oper- 
ation 34  times,  with  1  death.  It  is  probable  that  the  operation 
will  often  fail  to  cure  in  open  ulcer,  since  obstruction  has  no 
part  in  its  causation,  as  is  shown  by  the  existence  of  ulcers 
in  the  duodenum  beyond  the  pylorus.  It  can  be  readily  seen, 
therefore,  that  no  matter  how  large  the  opening  is  made,  the  food 
and  irritating  gastric  secretions  must  pass  over  the  ulcer  area 
to  reach  the  intestine.  The  conditions  calling  for  the  Finney 
operation  are  late  cicatricial  stenosis  and  contractures. 

All  in  all,  gastrojejunostomy  is  the  operation  of  choice.  It 
drains  the  stomach  rapidly  from  its  lowest  point,  and  from  the 
cardiac  side  to  the  left  of  the  ulcer-bearing  pyloric  region.  How- 
ever, the  procedure  has  some  drawbacks.  If  the  pylorus  is  not 
permanently  obstructed,  the  anastomotic  opening  may  contract. 
This  can  be  obviated  by  excising  the  pyloric  ring  or  running  a 
silver  wire  purse-string  suture  about  the  duodenum  immediately 
below  the  pylorus,  thus  producing  the  favorable  condition  of 
permanent  obstruction.  If  the  latter  condition  exists,  there  is 
little  danger  of  recontraction.  Anterior  gastro-jejunostomy  is 
liable  to  secondary  peptic  ulcer  of  the  jejunum  from  the  irritating 
gastric  secretions.  The  posterior  operation,  while  not  free  from 
this  disaster,  is  much  less  liable  to  it.  In  15  cases  which  Mikulicz 
found  recorded,  all  of  them  followed  the  anterior  operation.  All 
the  secondary  ulcers  were  found  either  on  the  intestinal  side  of 
the  anastomosis  or  immediately  below  the  opening.  Watts 
found  but  2  out  of  13  after  the  posterior  operation.  The  anterior 
operation  also  has  a  tendency  to  drag  on  the  attachment,  and 
contraction  is  more  frequent  than  after  the  posterior  operation, 
especially  if  the  Murphy  button  be  used.  The  suture  methods 
provide  a  larger  permanent  cicatricial  area  of  adhesion,  which 


(  IIHOMC    ri.CKU    OK    S'ln.MAril     AM)     IJIODKM   \t  '"-iO.'J 

|)ri'vciit.s  I  he  (livcrliciihua  t'oriiiat  ion  al  the  site  of  atliiNloiMo.si.s 
in  the  jejunum  so  often  seen  in  the  former  c-ases. 

In  (jur  experience  the  i)Osterior  suture  gastro-jejunostomy  is 
the  hesl  method  known  at  this  time.  As  to  the  manner  of  per- 
forming llie  ojjeration,  the  Murphy  button  makes  the  most  per- 
fect opening,  but  is  Hable  to  be  retained  in  the  stomach,  although 
this  is  seldom  a  cause  of  serious  after-trouble.  The  suture  meth- 
ods are  favoral)le,  inasmuch  as  the  opening  can  be  made  of  large 
size  to  guard  against  contraction.  However,  there  is  some  ten- 
dency to  the  formation  of  a  diaphragm.  To  a  certain  extent  this 
can  be  avoided  by  excising  the  nuicous  membrane  rather  freely  at 
the  opening,  as  advised  by  Moynihan.  The  McCiraw  ligature  is 
a  safe  method,  and  a  good  opening  can  be  secured.  There  is, 
however,  a  considerable  amount  of  scar-tissue  formation  about 
the  ring,  and  occasionally  a  bridge  of  mucous  adhesions  forms 
across  the  opening.  In  our  experience,  it  takes  from  six  to  eight 
days  for  the  opening  to  become  established  by  the  cutting  through 
of  the  rubber  ligature.  We  have  made  the  McGraw  ligature  ope- 
ration 15  times,  with  2  deaths,  but  we  have  used  it  in  the  worst 
class  of  cases,  in  which  other  methods  would  have  rendered  many 
of  the  operations  inadvisable.  This  procedure  is  particularly 
indicated  in  cancer,  and  by  the  anterior  method.  It  gives  time 
for  plastic  union,  and  requires  little  disturbance  of  tissues,  and, 
as  the  hydrochloric  acid  is  decreased  in  cancer,  there  is  little  or 
no  danger  of  secondary  jejunal  ulcer. 

Any  of  these  methods  will  give  good  results.  In  238  gastro- 
jejunostomies for  all  causes  which  have  been  made  (C.  H.  and 
W.  J.  Mayo),  there  was  a  mortality  in  the  malignant  cases  of 
25  per  cent.;  in  the  non-malignant,  of  about  7  per  cent.  The 
button  gave  7.5  per  cent.,  the  Mikulicz  suture,  5  per  cent.,  the 
McGraw  ligature,  13  per  cent.,  and  the  Finney  operation,  3  per 
cent.  The  percentage  of  secondary  operations  is  also  interesting. 
In  the  total  number  of  cases  (238)  there  were  14  secondary  opera- 
tions (G  per  cent.).  In  a  general  way  it  can  be  said  that  the  anterior 
method  of  gastrojejunostomy  gave  a  slightly  smaller  mortality, 
but  there  was  relatively  a  higher  percentage  of  reoperated  cases. 


206  WILLIAM   J.    MAYO 

In  other  words,  other  things  being  equal,  the  posterior  method 
gave  the  best  permanent  results,  with  but  a  slight  increase  of 
mortality. 

In  conclusion,  I  wish  to  speak  briefly  in  regard  to  cancer  of 
the  stomach.  Early  operation  is  a  prerequisite,  and  diagnostic 
exploratory  incision  is  necessary.  We  have  operated  upon  135 
cancers  of  the  stomach,  of  which  34  were  radical  extirpations; 
5  patients  died  within  a  month,  and  1  later  from  another  cause, 
too  early  to  know  the  ultimate  result  of  the  operation.  Of  the 
28  who  recovered,  the  average  length  of  life  was  over  a  year. 
One  lived  three  years  and  seven  months,  and  several  are  alive 
now,  after  more  than  two  years.  Sixty  per  cent,  of  cancers  are 
located  in  the  pyloric  portion,  that  is,  in  the  movable  part  of  the 
stomach.  The  lymphatic  arrangements  are  the  same  as  the 
vascular,  and  the  dome  of  the  stomach  is  isolated  from  this  portion, 
having  a  different  vascular  and  lymphatic  connection.  If  all  the 
lesser  curvature  with  the  corresponding  lesser  omentum,  and  all 
the  body  and  greater  curvature  to  the  left  gastro-epiploic  artery, 
be  removed,  the  results  in  cancer  of  the  pylorus  should  nearly 
equal  what  might  be  expected  after  complete  gastrectomy. 

The  remaining  portion  of  the  stomach  enables  intestinal  an- 
astomosis to  be  made  with  considerable  ease,  and  the  gastric 
pouch  rapidly  enlarges,  to  assume  the  function  of  the  stomach. 

The  operation  can  be  made  nearly  bloodless  by  tying  at 
proper  points  the  four  blood-vessels  which  nourish  the  stomach, 
much  as  is  the  case  in  hysterectomy.  By  making  the  division  of 
the  stomach  and  duodenum  with  the  actual  cautery,  wound  inoc- 
ulation is  prevented,  and  by  suturing  all  the  coats  with  catgut 
through  the  cauterized  area,  distal  to  the  holding  clamps,  neither 
the  stomach  nor  the  intestinal  canal  is  opened,  with  the  attendant 
risk  of  infection.  Lastly,  by  completely  closing  both  duodenal 
and  stomach  ends  permanently,  gastrojejunal  anastomosis  can  be 
effected  in  the  usual  way  at  a  healthy  situation  on  the  gastric  wall. 


RADICAL   OPERATIONS    FOR   THE   CURE   OF 
CANCER  OF  THE  PYLORIC  END  OF 
THE  STOMACH* 

WILLIAM    J.    MAYO 


Seventy  per  cent,  of  all  pistric  carcinomata  involve  the  pyloric 
portion  of  the  stomach,  and  60  per  cent,  have  their  origin  at  the 
pylorus  or  within  three  inches  of  it.  Considering  the  fact  that  the 
radical  operation  was  successfully  performed  in  the  time  of  Billroth 
(1881),  before  the  inception  of  modern  abdominal  surgery,  and 
that  during  the  succeeding  twenty-two  years  more  or  less  work 
has  been  done  in  this  field,  it  is  curious  to  note  that  pylorectomy 
and  partial  gastrectomy  have  not  as  yet  achieved  an  accepted 
.surgical  position.  There  have  been  a  number  of  reasons  for  this 
anomaly:  First,  a  belief  that  the  diagnosis  could  not  be  made  be- 
fore the  case  had  advanced  beyond  the  possibility  of  cure,  and. 
.second,  that  the  operation  was  difficult,  prolonged,  and  bloody, 
with  an  almost  prohibitive  mortality.  To  a  certain  extent  the 
first  consideration  is  true,  but  not  entirely  so,  as  we  have  in  ex- 
ploratory incision  the  one  diagnostic  resource  which  is  reliable, 
and  which  must  be  resorted  to  in  the  large  majority  of  cases  before 
a  surgical  diagnosis  can  be  made.  Without  exploration  the  truth 
is  but  slowly  established,  and  at  the  expense  of  progressive  hopeless 
involvement  for  the  patient.  Exploration  can  be  safely  accom- 
plished through  a  small  incision  and  with  a  short  period  of  dis- 
ability. It  may  be  said  that  the  patient  will  not  submit  to  an  ab- 
dominal incision  upon  suspicion,  but  herein  we  do  the  intelligence 
of  the  public  an  injustice.     We  have  seldom  been  refused  the  op- 

*  Reprinted  from  "Annals  of  Surgery."  March,  1904. 
207 


208  WILLIAM   J.    MAYO 

portunity,  when  the  matter  has  been  fairly  and  candidly  laid  before 
the  patient  and  his  friends.  The  plea  for  delay  has  more  often 
come  from  the  attending  physician. 

The  writer  is  of  the  opinion  that  an  early  diagnosis  must  be 
based  upon  clinical  phenomena,  the  result  of  observation  and  ex- 
perience. 

In  attempting  to  solve  some  of  these  problems,  we  have  en- 
countered a  number  of  misleading  statements  which  appear  to 
have  been  generally  accepted  by  the  medical  profession.  Three 
of  these  are  of  sufficient  importance  to  deserve  brief  discussion : 
(1)  The  value  of  laboratory  methods  of  diagnosis.  (2)  The  sig- 
nificance of  palpable  tumor.     (3)  The  history  of  previous  ulcer. 

1.  Laboratory  methods  of  diagnosis  are  based  chiefly  upon  the 
chemistry  of  the  gastric  secretions  (test-meals,  etc.)  and  the  mi- 
croscopic examination  and  chemical  reactions  of  gastric  findings, 
as  well  as  the  urine,  feces,  and  blood.  In  the  surgical  stage  these 
examinations  have  little  value,  but  they  gain  in  diagnostic  im- 
portance with  the  progress  of  the  disease  and  become  of  the  greatest 
value  when  the  patient  is  in  hopeless  condition.  In  the  examina- 
tion of  somewhat  over  1500  stomach  and  duodenal  cases,  of  which 
430  came  to  operative  demonstration,  Graham  and  Millet  showed 
this  beyond  question.  These  examinations  should  be  made,  but 
exploration  should  not  be  delayed  by  reason  of  the  inconclusive 
nature  of  the  results. 

2.  Tumor.  Many  years  ago  it  was  believed  that  the  presence 
of  a  tumor  demonstrated  inoperability.  This  is  by  no  means  true; 
a  small  movable  tumor  in  the  pyloric  region  may  be  a  favorable 
indication.  The  early  diagnosis  of  cancer  depends  in  a  great 
measure  upon  the  introduction  of  mechanical  phenomena  from 
obstruction  at  the  pylorus,  with  or  without  palpable  tumor;  and 
it  is  the  interference  with  gastric  motility  which  early  calls  the 
attention  of  the  patient  to  his  trouble,  and  not  the  presence  of  the 
cancer  itself.  Without  these  symptoms  a  surgical  diagnosis  would 
seldom  be  made.  In  our  experience  the  patient  with  marked 
symptoms  of  cancer  of  the  stomach,  but  without  any  evidence  of 
pyloric  obstruction,  proves,  on  exploration,  to  be  the  victim  of  ad- 


OPERATIONS  FOR  CANCER  OF  PYLORIC  EM)  OF  STOMACH    209 

vaiiccd  and  lio]K'le.s.s  disease  of  llie  bod\'  of  the  stoniacli,  in  wliich 
there  were  no  symptoms  during  the  operable  period. 

3.  A  history  of  previous  ulcer  with  complete  recovery  during  a 
prolonijcd  period  is  aj)t  to  be  taken  as  an  indication  that  the  present 
gastric  trouble  is  due  to  a  recurrence  of  the  ulcer,  and  leads  the 
patient  and  attending  physician  to  postpone  interference.  Usually 
this  is  true,  but  too  often  the  renewal  of  symptoms  is  due  to  cancer 
development  uj)on  an  ulcer  base.  We  have  had  this  occur  a 
number  of  times,  and  the  writer  has  become  a  convert  to  the  belief 
that  cancer  frequently  develops  upon  an  old  ulcer  scar.  In  145 
cases  of  cancer  of  the  stomach  which  came  to  operation  at  our 
hands  Graham  found  a  previous  history  of  ulcer  in  60  per  cent,  of 
the  cases,  although  years  may  have  elapsed  after  the  healing  of  the 
ulcer  before  the  cancer  began.  Lebert  says  that  9  per  cent,  of 
ulcers  develop  cancer,  that  is,  pass  directly  from  the  one  condition 
to  the  other.  Ochsner,  Futterer,  Dunn,  and  others  believe  that 
the  irritation  of  healed  ulcer  defects  in  the  mucosa  furnishes  the 
starting-point  for  the  majority  of  cancers.  Murphy  states  that 
precancerous  lesions  can  usually  be  demonstrated  in  the  history  of 
the  case.  It  is  to  be  noted  that  the  geography  of  cancer  and  ulcer 
is  nearly  identical. 

The  second  proposition  concerns  the  ulcer  itself.  There  are 
two  local  manifestations  of  the  malignant  process  upon  which  the 
advisability  of  operation  depends — (1)  Local  extent  of  disease; 
(2)  lymphatic  involvement. 

1.  Movability  of  the  growth  is  a  very  important  factor  in 
judging  the  extent  of  disease.  Limitation  to  the  pyloric  end  of  the 
stomach  is  also  of  importance.  Extension  to  neighboring  organs 
usually  contraindicates  operation,  with  the  occasional  exception 
of  the  transverse  mesocolon.  The  duodenum  is  rarely  involved 
to  any  considerable  extent.  Adhesions  are  a  serious  complication, 
not  only  because  they  are  the  advance  guard  of  the  cancerous  proc- 
ess, but  in  that  they  add  to  the  difficulties  and  dangers  of  the 
operation.  Haberkant  found  a  death-rate  of  73  per  cent,  operated 
upon  in  the  face  of  extensive  adhesions,  and  27  per  cent,  without 
such  com])lication.     Mikulicz  had  a  mortality  of  70  per  cent,  when 

VOL.  1—14 


■210  WILLLIM    J.    iL\YO 

there  was  close  adhesion  to  the  pancreas.  A  moderate  amount  of 
adhesions  which  permit  free  motihty  of  the  growth  has  not  ma- 
terially influenced  the  prognosis,  in  our  experience. 

2.  Lymphatic  infection.  This  is  the  most  important  element 
in  the  attempt  at  cure  of  cancer  of  the  stomach,  because  of  the  dif- 
ficulty in  estimating  its  extent.  The  mere  presence  of  enlarged 
lymph-nodes  does  not  necessarily  imply  cancer.  Glandular  hy- 
perplasia occurs  with  great  frequency  in  ulcer  as  the  result  of  in- 
fection, and  the  location  of  such  IjTnph-nodes  may  lead  to  the 
site  of  ulceration,  as  pointed  out  by  Lund.  Llcerating  gastric 
carcinomata  may  give  rise  to  infected  glands  without  epithelial 
invasion,  but  in  practically  all  cases  of  gastric  cancer  the  lymphatic 
structures  are  involved.  In  the  Breslau  clinic,  20  out  of  21  cases 
showed  glandular  involvement.  In  a  general  way  the  lymph- 
channels  follow  the  blood-vessels.  On  the  lesser  curvature  the 
blood-  and  lymph- vessels  lie  in  the  wall  of  the  stomach  itseK,  and, 
as  pointed  out  by  Mikulicz,  it  is  necessary  in  every  case  of  pyloric 
cancer  to  remove  all  the  lesser  curvature  to  the  gastric  artery. 
For  convenience,  this  situation  on  the  lesser  curvature  for  the  be- 
ginning of  the  line  of  excision  may  be  called  the  "Mikulicz  point 
of  election."' 

We  owe  a  debt  of  gratitude  to  Cuneo  for  his  masterly  exposition 
of  the  lymph  drainage  of  the  stomach.  He  showed  that  there  are 
but  few  lymph-glands  along  the  greater  curvature,  and  these  are 
confined  to  the  pyloric  region  (Fig.  15).  These  glands,  with  the 
blood-vessels,  are  set  at  some  distance  from  the  greater  curvature, 
thus  enabhng  rapid  expansion  and  contraction  of  the  stomach, 
without  interference  with  the  circulation.  The  lymph-stream  in 
this  situation  flows  from  left  to  right,  and  does  not  drain  more  than 
one-third  of  the  adjacent  stomach,  two-thirds  going  into  the  lymph- 
channels  of  the  lesser  curvature.  In  the  immediate  vicinity  of  the 
pylorus,  however,  it  drains  its  fair  share.  The  lymphatics  of  the 
greater  and  lesser  curvatures  enter  the  deep  receiving  glands  about 
the  celiac  axis  on  the  anterior  surface  of  the  aorta.  Cuneo  prac- 
tically demonstrated  that  the  fundus  and  two-thirds  of  the  greater 
curvature  are  free  from  lymphatic  involvement  in  cancer  of  the 


Willi/iM  J.t-Uro. 


--^^ 


f  Pneumo^siric  Left-  - 
I 

Ganglion 

Pneumojasinc  Rijht 


Hepatic  artery  -^^ 


Ganglio 

Gastro-cpiploic 
vein 


Fig.  15.— Showiii};  an;iti)my  of  tlic  slDniach,  with  cspociul  rcfcrtnce  to  clistribiitinn  of  the  lymphatics. 


OPERATIONS  FOR  (AXf  KR  OK  PYLORIC  KM)  OF  STOMACH        '■^' 1  1 

pylorus.  IIurLinanu  at  oik-c  seized  upon  lliis  hasic  princijile  and 
fixed  the  point  of  election  for  the  line  of  section  upon  the  greater 
curvature  at  a  healthy  i)lace  on  the  gastric  walK  to  the  left  of  these 
glands.  The  distance  to  the  left  is  regulated  by  the  extent  of 
disease.  In  a  previous  communication  the  writer  called  attention 
to  the  lymphatic  isolation  of  the  dome  of  the  stomach.  This  has 
also  been  noted  by  Robson  and  Moynihan.  It  is  evident  that  the 
extent  of  this  free  zone  along  the  greater  curvature  is  much  wider 
in  i)yloric  cancer  than  was  at  that  time  considered  possible.  The 
retention  of  this  portion  of  the  stomach  relieves  the  operation  of 
many  serious  difficulties  without  loss  of  completeness. 

The  patient's  stomach  should  be  cleaned  the  day  before  rather 
than  immediately  previous  to  operation,  as  it  may  prove  to  be 
rather  trying  to  one  unaccustomed  to  the  process.  A  small  amount 
of  liquid  nourishment  may  be  given  after  the  lavage,  but  nothing 
on  the  morning  of  the  operation.  The  teeth  and  mouth  should 
have  been  previously  cleansed  as  well  as  possible.  A  preliminary 
hypodermatic  injection  of  morphin,  to  enable  the  anesthetic  to  be 
reduced  to  a  minimum,  may  be  of  value. 

The  operation  itself  can  be  divided  into:  (a)  Incision  and 
exposure;  (6)  control  of  hemorrhage;  (c)  closing  of  the  stomach 
and  duodenal  stumps;  (d)  reestablishment  of  the  gastro-intestinal 
canal;  (e)  avoidance  of  infection;  (/)  measures  for  preventing 
shock. 

(a)  A  small  incision  is  made  in  the  median  line,  half-way  be- 
tween the  ensiform  cartilage  and  the  umbilicus;  through  this 
two  fingers  are  introduced  for  exploration.  If  the  condition  is 
inoperable,  the  incision  is  closed,  and  a  sufficient  number  of  buried 
non-absorbable  mattress  sutures  of  silk,  linen,  or  wire  introduced 
into  the  aponeurotic  structure  of  the  linea  alba  to  enable  the  patient 
to  get  about  at  once  and  to  return  to  his  friends  within  a  few  days. 

Non-absorbable  sutures,  buried  in  fixed  structures,  such  as 
fascia  and  bone,  seldom  give  trouble,  and  furnish  immediate 
strength.  In  muscle  and  movable  tissues,  atrophy  necrosis  may 
occur.  We  limit  their  use,  however,  to  the  hopeless  cases  of  ex- 
ploration for  malignant  disease.     If  operation  is  decided  uj^on.  the 


212  WILLIAM   J.    ilAYO 

small  exploring  incision  is  rapidly  enlarged  to  four  or  five  inches, 
and  a  sufficiency  of  the  gastrohepatic  omentum  is  tied  off  at  once 
close  to  the  liver.  This  opens  the  lesser  cavity  of  the  peritoneum 
and  mobilizes  the  pyloric  end  of  the  stomach  ^dth  tumor.  The 
entire  area  is  now  packed  off  with  gauze  pads. 

(b)  Control  of  hemorrhage.  The  pyloric  end  of  the  stomach 
is  suppHed  by  four  blood-vessels — the  gastric  and  superior  pyloric 
above,  and  the  right  and  left  gastro-epiploics  below.  By  ligating 
these  four  vessels  early,  the  operation  is  rendered  practically  blood- 
less. The  gastric  is  doubly  tied  about  one  inch  below  the  cardiac 
orifice,  at  a  point  where  it  joins  the  lesser  curvature,  and  divided 
between  the  ligatures.  The  superior  pyloric  is  doubly  tied  and 
divided.  The  fingers  are  passed  beneath  the  pylorus,  raising  the 
gastrocolic  omentum  from  the  transverse  mesocolon,  and  in  this 
way  safe  hgation  behind  the  pylorus  of  the  right  gastro-epiploic 
artery,  or  in  most  cases  its  parent  vessel,  the  gastroduodenal,  is 
secured  (Fig.  16).  The  left  gastro-epiploic  is  now  tied  at  an  appro- 
priate point,  and  the  necessary  aniount  of  gastrocolic  omentum 
doubly  tied  and  cut.  Sometimes  the  right  margin  of  the  omen- 
tum becomes  very  much  congested  from  the  venous  obstruction 
produced  in  this  way.  In  a  few  cases  it  has  seemed  wise  to  excise 
the  devitahzed  omentum,  especially  if  drainage  is  to  be  used,  with 
its  attendant  possibilities  of  secondary  infection.  In  one  such  case 
a  considerable  amount  of  omental  tissue  sloughed,  although, 
fortunately,  the  patient  recovered.  If  drainage  is  not  used,  it  will 
act  as  an  omental  graft  and  give  no  trouble.  It  is  important  that, 
in  ligating  the  gastroduodenal  vessel  and  the  gastrocolic  omentum, 
the  fingers  should  raise  the  structures  away  from  the  middle  colic 
artery,  which  runs  immediately  beneath  in  the  transverse  meso- 
colon (Fig.  17). 

The  lesser  cavity  of  the  peritoneum  is  a  potential  rather  than 
an  actual  space,  as  the  two  layers  of  peritoneum  are  in  contact, 
and  the  middle  colic  has  been  accidentally  caught  in  tying  the 
vessels  from  without  inward.  As  this  vessel  usually  supplies 
the  entire  transverse  colon,  ligation  may  result  in  gangrene  of 
the  transverse  colon,  as  pointed  out  by  Kronlein.     This  has  hap- 


Mikulicz-Hart- 
mann  line. 


Fig.  i6. — Showing  ligation  of  pastrohcpatic  omentum  and  superior  vessels  in  such  manner  as 
to  leave  all  the  lymph-nodes  attached  to  the  part  of  the  stomach  to  be  e.xcised;  also  lines  of  division 
of  duodenum  and  stomach. 


WilliAm  J  Mayo. 


Fig.  17. — Showing  methods  of  excision.     Note  that  all  the  glands  on  the  greater  curvature  are  removed 

in  every  case 


OI'KUATIONS    I  ()U  CANCKIt  OF  PVI.OHIC    DM)  Ol'  STO.NJACH        '2]'i 

jx'iu'd  u  muiil)<.'r  of  tiiifs.  Tlic  (•(jiiLnjl  ol'  Ju-inorrliaj^c  is  \cry 
similar  to  the  ligalioii  ol"  tlic  loiir  vessels  concerned  in  abdominal 
hystcreclomy  and  t'lilly  as  easy. 

(c)  The  duodcmmi  is  doubly  damped  and  divided  between  willi 
the  actual  eaulery,  to  pn^vent  inoculation  of  the  cut  surfaces  with 
cancer  (Fig.  !(>)•  '  l'*'  'I'lodenal  stump  should  be  left  one-fourth 
inch  long,  and,  before  removing  liie  clamj),  a  running  suture  of  cat- 
gut is  introduced  through  the  scared  stumj)  and  tied  as  the  clamp 
is  removed.  A  purse-string  suture  of  silk  or  linen,  three-quarters 
of  an  inch  below  the  stump,  enables  inversion  in  a  similar  manner 
to  the  stunij)  of  the  aj)pendix  (Figs.  IG  and  17).  A  long  Kocher 
holding  clamp  is  now  placed  from  the  tied  gastric  artery  at  Miku- 
licz's point  of  election  in  an  oblique  direction,  so  as  to  save  as  much 
as  possible  of  the  greater  curvature  to  Hartmann's  point  of  election 
on  the  greater  curvature  (Fig.  17).  The  blades  of  this  clamp  should 
be  covered  witli  rubber  tubing,  and  the  compression  sliould  be  just 
sufficient  to  retain  the  tissues  in  its  grasp.  A  second  clamp  is 
applied  on  the  tumor  side  to  prevent  leakage.  The  tissues  between 
are  severed  with  the  Paquclin  cautery,  one-quarter  of  an  inch  from 
the  holding  clamp,  and,  as  the  tissues  are  divided,  several  catch 
forceps  are  caught  on  the  projecting  stump,  to  prevent  retraction 
of  some  part  of  the  gastric  wall  from  the  grasp  of  the  Kocher  clami). 
The  pyloric  end  of  the  stomach,  with  the  tumor  guarded  against 
leakage  by  the  clamp  at  each  end,  is  removed.  The  cauterized 
stump  projecting  beyond  the  Kocher  clamp  is  rapidly  sutured  with 
a  catgut  buttonhole  suture,  from  the  greater  to  the  lesser  curva- 
ture, through  all  the  coats  of  the  stomach,  and  in  the  same  manner 
directly  back,  and  tied  at  the  starting-point;  this  prevents  hemor- 
rhage as  well  as  leakage  (Fig.  18).  The  doubling  of  this  form  of 
suture  holds  the  approximated  edges  evenly  in  line.  The  Kocher 
clamp  is  now  removed,  and  any  bleeding  point  caught  and  tied. 

The  final  suture  of  silk  or  linen  is  now  introduced,  made  aiter 
the  right-angled  plan  of  Cushing.  It  is  taken  sufficiently  far  from 
the  catgut  suture  line  to  enable  easy  approximation  of  the  sero- 
muscular layers  without  tension  (Fig.  19). 

Steps  b  and  c  can  be  varied  sometimes  to  advantage.     We  have 


214  ^VILLIAM   J.    MAYO 

frequently  tied  off  the  gastrohepatic  ligament  and  the  superior 
vessels,  and  at  once  double  clamped  and  divided  the  duodenum. 
By  pulling  upward  on  the  stomach  side  the  gastroduodenal  artery 
is  easily  caught,  tied,  and  divided,  and  the  operation  proceeded 
with  as  before.  In  a  few  cases  we  have  begun  on  the  stomach  side, 
ligating  and  dividing  the  gastric  and  left  gastro-epiploic  vessels 
first,  then  clamping,  di^nding,  and  suturing  the  stomach  as  before. 
Complete  the  duodenal  end  with  its  vessels  last.  This  is  favored 
bj"  Hartmann.  If  there  are  adhesions,  however,  the  first  plan 
mobilizes  the  stomach  much  better,  and  enables  more  accurate 
work  and  greater  exposure  of  that  part  of  the  stomach,  which  at 
the  line  of  section  lies  naturally  deep  under  the  costal  arch. 

(d)  Restoration  of  the  gastro-intestinal  canal  was  first  ac- 
complished by  Billroth,  by  joining  directly  the  cut  surface  of  the 
duodenum  to  the  shortened  stomach,  the  opening  of  the  latter 
viscus  being  partly  sutured  to  reduce  it  to  the  size  of  the  duodenal 
end.  The  angle  where  the  three  suture  lines  came  together  leaked 
so  often,  especially  if  there  was  the  least  tension,  that  it  was  called 
the  "fatal  suture  angle."  Kocher  saw  the  defect  in  this  method, 
and  began  implanting  the  cut  end  of  the  duodenum  to  the  posterior 
gastric  wall  at  a  sound  point,  and  completely  closed  the  stomach. 
This  method  gives  excellent  results,  if  there  be  no  tension,  in 
bringing  the  parts  into  easy,  apposition.  Unfortunately,  this 
tension  occurs  often. 

Billroth's  second  operation  is  the  operation  of  choice:  complete 
closure  of  the  duodenal  and  stomach  ends  with  an  independent 
gastrojejunostomy  of  the  usual  type.  It  has  the  two  chief  requi- 
sites of  gastro-intestinal  anastomosis;  there  is  no  tension,  and  the 
parts  to  be  united  have  not  been  injured.  Either  the  anterior  or 
posterior  method  can  be  used,  and  the  Murphy  button  or  suture 
operation  be  performed.  If  the  patient  is  in  good  condition  and 
the  operation  has  been  completed  promptly,  we  prefer  the  posterior 
suture  method;  if  the  patient's  condition  is  poor,  the  anterior 
button  operation  is  chosen  (Fig.  19). 

(e)  The  question  of  cancer  infection  grafted  upon  a  raw 
surface  is  an  important  one.     We  have  seen  carcinomatous  nodes 


i;,llM-nJ  M><o. 


Fig.  iS.^Showing  closure  of  cut  duodenal  end  by  circular  suture  and  first  row  of  sutures  being  placed 

on  the  stomach  side. 


WilliAn,  JMayo. 


Fig.   ig. — Showing  completed  operation. 


OPKUATIONS   F()I{  CAXCKU  OF   I'YI.OHIf   KM)  f>F  STCj.MArH        21.3 

develop  in  llic  alxloiiiinal  incision  and  in  I  lie  alxioniinal  need!*' 
[jiUK'lnres  made  in  snlurin^  llic  alxioniinal  wall  al'lcr  partial 
gaslrccloniy.  Disseininalion  of  carcinonia  hy  rougli  liandlirif^  or 
allowing  infected  cells  to  escape  into  the  wound  is  not  uncommon. 
It  is  for  this  reason  that  all  .sections  of  the  disea.sed  part  are  made 
witli  the  actual  cautery,  which  prevents  inoculation  of  raw  surfaces 
and  checks  capillary  hemorrhage,  and  leaves  the  ajjfjroximated 
ends  in  an  asej)tic  condition  until  they  are  digested  hack  to  the 
outer  suture  line.  Pyogenic  infection  is  prevented  by  the  clamps 
placed  upon  each  side  of  the  excised  stomach,  sealing  against  escape 
of  contents,  while  the  exposed  edges  beyond  the  clamp  are  sterilized 
by  the  use  of  the  cautery  in  making  the  section.  In  addition  to 
this  the  gauze  pads  are  arranged  in  two  rows — an  outer  deep  layer, 
which  is  not  changed  until  final  removal,  and  an  inner  superficial 
layer,  which  is  being  constantly  renewed.  Upon  removal  of  the 
final  gauze  pack  the  entire  field  is  carefully  gone  over  and  any  little 
bleeding  point  checked  by  ligature.  After  sponging  the  surfaces 
with  a  moist  saline  gauze  pad,  the  abdominal  incision  is  closed. 
In  some  cases  drainage  seems  wise  on  account  of  accidental  soiling. 
This  is  seldom  necessary,  but  if  in  doubt,  drain,  with  a  cigarette 
drain  placed  at  the  lower  angle  of  the  external  wound,  entirely 
away  from  the  visceral  suture  lines.  The  internal  end  of  the  drain 
should  reach  a  situation  just  above  the  transverse  colon,  which 
acts  as  a  dam  when  the  patient  is  placed  in  the  proper  position  in 
bed,  head  and  shoulders  elevated.  In  this  half-sitting  posture  the 
little  pouch  formed  by  the  transverse  colon  is  not  unlike  an  artificial 
pelvis  into  which  any  fluids  gravitate.  If  but  a  limited  area  is  to 
be  quarantined,  the  gauze  should  be  brought  out  in  the  most  direct 
manner  possible. 

(/)  If  the  patient  is  in  good  condition,  there  is  practically  no 
shock,  because  there  is  no  l)lood  loss  and  but  little  exposure  of 
abdominal  contents.  The  operation  proceeds  systematically, 
and  can  be  done  in  a  suitable  case  by  the  average  operator, 
from  the  beginning  of  the  abdominal  incision  until  it  is  closed,  in 
from  fifty  minutes  to  one  hour  and  fifteen  minutes.  If  the  patient 
is  in  bad  condition,  owing  to  early  obstruction,  the  chief  danger 


216  WILLIAM   J.    MAYO 

comes  from  the  lack  of  fluids  in  the  body.  As  suggested  by  Dudley 
Allen,  this  should  be  made  up  by  subcutaneous  injections  of  saline 
solution,  40  to  60  ounces  a  day,  usually  20  to  30  ounces  every  twelve 
hours,  for  two  days  previous  to  the  operation.  This  is  continued 
for  several  days  following  operation,  if  necessary.  For  subcu- 
taneous injections  we  prefer  the  ordinary  Davidson  syringe,  to 
which  is  attached  an  aspirating  needle.  The  hand-bulb  regulates 
the  inflow.  The  injection  can  be  given  by  a  nurse  as  easily  as 
an  enema.  In  debilitated  patients  very  little  anesthetic  is  used — 
just  enough  to  enable  the  surgeon  to  open  and  close  the  abdomen. 
All  the  visceral  work  can  be  done  without  pain.  The  previous 
administration  of  morphin  keeps  the  patient  from  becoming 
nervous. 

An  enema  of  6  ounces  of  coffee  is  given  as  soon  as  the  patient  is 
put  to  bed.  If  necessary,  morphin,  strychnin,  or  like  remedies  are 
given. 

The  after-treatment  is  simple — the  head  and  shoulders  of  the 
patient  are  raised  by  four  or  five  pillows,  rectal  alimentation  is 
instituted,  hot  water  by  mouth  after  twelve  hours  in  tablespoonful 
doses,  increased  to  an  ounce  every  hour.  After  thirty-six  hours 
the  usual  experimentation  with  liquid  foods  is  begun. 

To  recapitulate,  there  are  six  important  stages  to  the  operation 
as  outlined: 

1.  Open  the  abdomen. 

2.  Doubleligateanddivide  the  gastric  artery;  ligate  and  divide 
the  necessary  amount  of  gastrohepatic  omentum  close  to  the  liver, 
leaving  most  of  its  structure  attached  to  the  stomach.  Double 
ligate  and  divide  the  superior  pyloric  artery  and  free  the  upper  inch 
or  more  of  the  duodenum  (Fig.  16). 

3.  With  the  fingers  as  a  guide  underneath  the  pylorus,  in  the 
lesser  cavity  of  the  peritoneum,  ligate  the  right  gastro-epiploic  or 
gastro-duodenal  artery,  and  progressively  tie  and  cut  away  the 
gastrocolic  omentum  distal  to  the  glands  and  vessels  up  to  the  ap- 
propriate point  on  the  greater  curvature,  and  here  ligate  the  left 
gastro-epiploic  vessels  (Fig.  17). 

4.  Double  clamp    the    duodenum,   divide    between  with    the 


OPERATIONS  FOR  fAXfER  OF  PYLORIC  END  OF  STOMAf  H        -217 

cautery,  lcii\in^  oiio-l'ourlli  iiuli  projection.  \N  itli  a  rumiiiifj;  su- 
ture of  catgut  through  the  scared  stump  the  end  of  the  duodeuuin 
is  closed  as  the  clamp  is  removed.  A  purse-string  suture  about 
the  duodenum  enables  the  stump  to  be  inverted  (Figs.  10  and  17). 
The  ])roxiinal  end  of  the  stomach  is  double  clamped  along  the 
Mikulicz-Hartniaiin  line  (F'ig.  17),  and  divided  with  the  cauterj", 
leaving  one-fourth  inch  projection.  Suture  through  the  seared 
stump  with  a  catgut  buttonhole  suture.  This  is  again  turned  in 
after  removal  of  the  clamp  by  a  continuous  silk  or  Gushing  suture 
(Figs.  18  and  19). 

5.  Independent  gastrojejunostomy  (Fig.  19). 

6.  Closure  of  the  wound. 

Forty-one  radical  operations  on  the  pyloric  end  of  the  stom- 
ach, 37  for  cancer,  and  4  for  inveterate  ulcer,  have  been  performed 
by  C.  H.  Mayo  and  the  writer.  Of  these,  13  have  been  done  es- 
sentially by  the  plan  outlined  above,  with  1  death.  There  were  6 
deaths  in  the  remaining  28  cases,  performed  by  various  methods. 
In  the  last  11  cases  this  technic  was  used  practically  as  given,  and 
there  were  no  deaths.  Making  all  due  allowance  for  increased  ex- 
perience and  possibly  a  better  selection  of  cases,  the  difference  is 
too  marked  to  be  entirely  accidental.  It  is  hardly  necessary  to 
say  that  this  is  a  composite  operation,  and  in  no  sense  to  be  con- 
sidered original. 

In  a  previous  contribution  on  this  subject,  published  in  the 
"Annals  of  Surgery"  July,  1903,  a  somewhat  similar  operation 
was  recommended  by  the  writer,  only  that  it  was  far  more  ex- 
tensive, removing  all  the  stomach  except  the  dome.  With  in- 
creased observation  and  experience  I  believe  that  the  former  opera- 
tion, with  a  mortality  of  3  deaths  in  8  cases,  is  unnecessarily  severe 
for  the  average  case  of  pyloric  cancer.  The  operation  described 
at  that  time  has  a  place  in  surgery,  and  should  be  used  in  the  cases 
of  extensive  disease  involving  the  body  of  the  stomach.  In  these 
cases  it  has  practically  all  the  advantages  of  complete  removal  of 
the  stomach,  and  should  be  used  as  a  substitute  for  total  gastrec- 
tomy, where  possible. 


ULCER  AND  CANCER  OF  THE  STOMACH  FROM 
A  SURGICAL  STANDPOINT* 


WILLIAM    T.    MAYO 


Disease  of  the  stomach  is  one  of  the  most  important  subjects 
before  the  medical  profession  today.  Heretofore  these  conditions 
have  been  considered  almost  entirely  from  a  medical  point  of  view, 
and  it  is  only  of  late  that  their  surgical  possibilities  are  beginning 
to  be  recognized. 

The  treatment  of  gastric  disorders  has  been  based  upon  chem- 
istry, and  for  two  decads  hydrochloric  acid  and  pepsin  have  formed 
the  chief  ammunition  which  has  been  fired  at  diseases  of  the  stom- 
ach. During  this  time  a  feeling  has  gradually  developed  that  these 
means  were  inefficient,  and  while  many  investigators  have  turned 
toward  new  pharmacopeial  combinations,  there  has  also  been  an 
intelligent  effort  toward  a  better  understanding  of  the  functions  of 
the  stomach,  and  with  this,  a  different  version  as  to  its  pathology. 
The  mechanics  of  the  stomach  are  usually  at  fault,  and  not  its 
chemics,  and  it  is  for  this  reason  that  surgery  is  rapidly  invading 
the  field.  I  would  not  be  understood  as  saying  that  even  the 
greater  proportion  of  diseases  of  the  stomach  are  surgical;  but 
that  the  majority  of  serious  lesions  may  become  so  cannot  be 
doubted,  and  it  is  also  true  that  a  very  large  proportion  of  chronic 
gastric  disorders  are  due  to  faulty  mechanics  and  must  have  sur- 
gical interference. 

While  the  stomach  absorbs  fluids  and  equalizes  the  temperature 
of  the  ingesta,  it  does  not  digest  the  food;  but  with  a  weak  solution 
of  pepsin  and  hydrochloric  acid  it  macerates  the  ingested  material, 
and  the  pyloric  portion  breaks  up  the  food-masses  by  a  grinding 

*  Reprinted  from  "The  Medical  News,"  April  16,  1904. 
218 


I  L(  I;K    .wo    (  ANTKU    ok    SJOMAril  219 

inolioii.  As  llic  pnjccss  is  coinplcled  tlie  pHxiuct  is  turned  into 
tlie  small  intestine,  where  digestion  and  assimilation  are  accom- 
plished. 

The  mnscuhir  action  of  the  stomach  is  of  a  twofold  nature:  the 
fundus  contracts  rather  slowly  upon  the  food  material,  forcing  it 
toward  the  pyloric  end,  which  grinds  and  pulverizes  it  into  a 
harmonious  whole,  the  fundus  being  the  hoj)per,  and  the  j)yloric 
[)ortion  the  grinding-stones.  It  can  readily  he  seen  that  an  ob- 
struction at  the  outlet  produces  dilatation  with  retention  or  stag- 
nation of  the  food,  and  this  often  results  in  fermentation  and  ab- 
sorj)tion  of  deleterious  products.  The  extent  of  the  disorder 
depends  upon  the  degree  of  obstruction  and  the  compensatory  hy- 
pertrophy of  the  musculature  of  the  stomach.  Many  of  these 
cases  develop  a  degree  of  hypermotility  which  equalizes  the  ob- 
struction. In  other  cases  a  period  of  compensation  alternates 
with  muscle  failure,  exactly  like  valvular  heart  lesions  and  their 
effect  ui)on  the  cardiac  muscle.  We  see  the  same  phenomena  in 
obstructions  at  the  outlet  of  the  gall-bladder  and  at  the  pelvis  of 
the  kidney,  and  again  in  the  urinary  bladder — all  organs  with  a 
temporary  storage  function  and  a  limited  outlet.  Even  with 
moderate  obstructive  dilatation  the  victim  begins  to  diet,  and  in 
the  main  "diet"  means  restricted  food-supply — an  attempt  to 
reduce  the  amount  of  work  to  be  done  by  the  stomach  to  the 
minimum.  In  the  extreme  cases  the  solids  are  first  eliminated 
from  the  dietary  because,  as  has  been  pointed  out,  the  stomach 
does  not  assimilate  such  articles  of  food,  and  the  bulk  increases 
the  difficulty  of  passing  the  obstruction.  Fluids,  on  the  contrary, 
are  absorbed  to  a  certain  degree,  and  also  more  easily  pass  the  con- 
tracted outlet.  Therefore,  foods  with  much  fluids  and  little  resi- 
due are  chosen. 

The  stomach  may  become  enormously  distended,  and  even  the 
absorption  of  fluids  be  reduced  to  small  proportions.  So  true  is 
this  that  Cramer  was  able  to  demonstrate,  by  the  quantity  of 
urine  passed,  the  degree  of  dilatation  and  the  amount  of  gastric 
function.  He  divides  these  cases  into  three  grades,  as  shown  by 
the  urine  collected  for  twentv-four  hours:    First  degree,  1500  to 


220  WILLIAM   J.    MAYO 

1000  c.c;  second,  from  900  to  500  c.c;  and  third,  all  cases  falling 
below  500  c.c,  and  further  says  that  lavage  of  the  stomach  which 
contains  much  material,  with  urine  below  500  c.c,  may  dilute  the 
toxic  products  in  the  stomach  and  render  them  more  readily  ab- 
sorbable. Tetany  has  its  onset  immediately  following  the  use  of 
the  tube  in  many  reported  cases.  The  stomach  should  be  emptied 
some  hours  before  lavage  is  practised  in  such  cases.  That  these 
products  of  retention  and  fermentation  are  poisonous  cannot  be 
questioned.  We  had  one  case  in  which  gastro-enterostomy 
turned  a  great  amount  of  such  material  into  the  small  bowel  and 
the  patient  promptly  died  from  toxemia,  which  followed  the  ab- 
sorption. The  symptoms  resembled  the  effect  of  cadaverin  upon 
animals.  Gastric  tetany  probably  depends  for  its  origin  upon  the 
absorption  of  retention  products.  The  severe  grades  are  the  only 
ones  which  we  have  heretofore  recognized.  They  have  been  ex- 
ceedingly serious.  In  40  cases  Albu  found  31  deaths.  Mild 
grades,  however,  are  much  more  common,  and  are  apt  to  be  over- 
looked. Muscle-twitching,  prickling  sensations,  and  so  forth  in 
connection  with  serious  dilatation  are  to  be  looked  upon  as  warnings 
and  surgery  should  not  be  long  delayed.  Cramer  has  recently 
written  exhaustively  upon  this  subject. 

The  popularity  of  the  stomach-tube  depends  upon  the  mechan- 
ical removal  of  food  remnants,  which  would  otherwise  stagnate  in 
the  stomach ;  but  it  does  not  cure  any  more  than  the  catheter 
which  is  used  to  relieve  urinary  retention  or  residual  urine  cures 
the  prostatic  hypertrophy  upon  which  the  condition  depends. 
The  stomach-tube  relieves  the  temporary  obstruction,  and  may 
aid  restoration  of  compensation  by  giving  time  for  muscular  de- 
velopment; but  our  faith  in  the  ability  of  gastric  lavage,  either 
plain  or  medicated,  to  cure  mechanical  obstructions  has  been 
shattered  beyond  repair. 

It  is  not  my  purpose  to  discuss  in  detail  the  nature  of  the  various 
obstructions,  but  rather  to  indicate  the  effect  of  such  interference 
upon  gastric  motility,  and  to  call  attention  to  the  fact  that  serious 
or  progressive  obstructions  are  surgical  conditions,  and  that  dila- 
tation of  the  stomach  and  its  degree  is  the  sign-post  which  tells  us 


LTXKU    AND    (.ANCKU    OK    ST(jMA(  ||  !2'-21 

the  projjor  course  of  action.  If  the  lesser  ciir\'atiire  is  in  normal 
position  and  the  «^reater  curvature  of  the  stomach  lies  l)elo\v  the 
umbilicus,  some  degree  of  dilatation  is  i)resent.  If  the  stomach 
is  prolapsed,  the  distance  between  the  curvatures,  demonstrated 
by  air  inflation,  will  readily  show  the  amount  of  dilatation.  The 
tartaric  acid  and  bicarbonate  of  soda  test  is  sudden,  and  in  certain 
cases  there  is  danger  of  rupturing  a  weakened  gastric  wall.  W  itli 
an  ordinary  Davidson  syrin<ie  or  bicycle  j)unij)  and  a  stomach-tube 
the  stomach  can  be  easily  filled  with  air  and  its  outline  marked 
upon  the  skin.  Cramer  says  that  any  dilatation  not  vastly  im- 
proved in  four  weeks  under  gastric  lavage,  dietary,  and  massage  for 
muscle  building  should  be  subjected  to  operation.  Loss  of  stomach 
motility  in  its  lesser  degrees  is  not  necessarily  obstructive.  For 
instance,  in  gastric  atony  and  in  the  neurasthenic  state  loss  of 
motility  is  not  infrequently  neurotic  in  origin,  and  often  accom- 
panied by  hyperchlorhydria.  These  conditions  carry  with  them 
stigmata  that  will  not  be  easily  overlooked.  Stagnation  and  re- 
tention of  food  do  not  occur  for  any  length  of  time  in  such  cases. 

Turning  from  the  most  common  causes  of  interference  with 
the  function  of  the  stomach,  due  to  obstruction  of  outflow,  we 
come  to  the  second  great  class  of  gastric  disorders  in  which  disease 
of  the  wall  of  the  stomach  prevents  its  reservoir  function  or  limits 
its  grinding  power,  that  is,  ulcer  and  cancer  of  the  stomach.  The 
most  common  seat  of  these  lesions  is  in  the  pyloric  portion,  and 
they  are  intimately  associated  with  the  etiology  of  the  obstructions, 
deformities,  and  tumors  upon  which  the  dilatation  depends. 
These  latter  conditions  are  to  be  looked  upon  as  a  result  of  ulcer 
or  cancer  of  the  stomach.  There  are,  of  course,  many  other  causes 
of  obstruction,  such  as  valve  formation  at  the  pylorus,  but  they 
are  the  exceptions  which  prove  the  rule. 

Ulcer  of  the  Stomach. — Simple  ulcer  of  the  stomach  is  by 
no  means  the  rare  condition  which  we  have  been  led  to  believe. 
The  acute  form,  with  its  classic  symptoms,  pain,  vomiting,  hemor- 
rhage, local  tenderness,  and  hyperchlorhydria,  forms  a  grouj)  of 
synn)toms  which  is  readily  recognized,  and  the  treatment  should  be 
medical.     Surgery  has  to  do  only  with  the  complications,  such  as 


222  WILLIAM   J.    MAYO 

hemorrhage  or  perforation.  It  is  altogether  probable  that  the 
vast  majority  of  acute  ulcers  heal,  but  a  considerable  minority  fail 
to  do  so  and  constitute  a  share  of  the  chronic  ulcers. 

Acute  exacerbations  of  a  chronic  ulcer  must  not  be  mistaken  for 
acute  ulcer,  as  is  too  often  done,  and  the  subsidence  of  the  acute 
period  mistaken  for  cure  of  the  original  condition.  Chronic  ulcer 
is  frequently,  if  not  usually,  chronic  from  its  inception,  its  course 
being  marked  by  a  period  of  symptoms  lasting  from  a  few  days  to 
weeks,  to  be  followed  by  a  longer  period  of  apparent  betterment, 
lasting  some  weeks  or  months.  These  patients  go  from  one  phy- 
sician to  another,  each  acute  attack  a  medical  cure — it  is  the  old 
story  of  appendicitis  and  gall-stones  over  again.  Failure  to  stay 
well  impels  the  victim  to  seek  new  aid,  and,  often  enough,  each 
physician  believes  the  cure  to  be  permanent.  Ultimately  the 
patient,  unrelieved  by  legitimate  medicine,  much  to  our  disgust 
takes  to  the  charlatan  and  patent  medicine  vender.  These  cases 
are  surgical.  They  are  chronic  because  treatment  has  been  tried 
over  and  over  again  and  has  failed. 

Etiology. — The  etiology  of  gastric  ulcer  is  obscure.  There  are 
three  known  factors  of  great  importance:  First,  anemia;  second, 
hyperchlorhydria;  and  third,  mechanical  injury.  Anemia  is  cer- 
tainly a  very  important  element,  particularly  at  the  inception  of 
the  disease,  acute  round  ulcer  being  by  no  means  a  rare  occur- 
rence in  the  chlorotic  state.  Overcoming  the  anemia  often  does 
much  to  establish  a  cure.  In  the  chronic  forms  this  anemia  may 
be  continued  and  depend  upon  a  slow  loss  of  blood.  Murphy  has 
pointed  out  its  close  resemblance  to  the  pernicious  type.  In  some 
cases  the  postmortem  is  the  only  means  of  clearing  up  the  diag- 
nosis. 

Hyperchlorhydria  is  usually  present  at  some  time  in  the  history 
of  peptic  ulcer,  and  in  most  cases  it  is  present  at  all  times.  That 
it  is  of  the  utmost  etiologic  importance  is  shown  by  the  frequency 
of  duodenal  ulcers  of  the  peptic  type  above  the  opening  of  the  com- 
mon duct  with  its  alkaline  discharges,  and  the  occurrence  of  secon- 
dary peptic  ulcer  in  the  jejunum  at  or  near  the  opening  made  by 
gastrojejunostomy  for  drainage  of  gastric  ulcer. 


ULCER  AND  CANCKU  OK  STOMACH  ^'23 

MccliJiniciil  injury  is  also  an  important  factor,  as  shown  by  tlip 
location  of  7o  per  cent,  of  j^astrie  ulcers  in  the  grinding  aj)paratus 
of  the  pyloric  end  of  the  stomach,  although  having  not  more  than 
one-sixth  of  the  ex[)osed  mucous  membrane.  It  is  for  this  reason 
that  gastrojejunostomy  has  given  such  signal  relief.  The  anemia 
is  overcome  by  good  feeding,  the  hyperchlorhydria  by  the  rapid 
drainage  of  the  gastric  juices  into  the  intestine,  with  its  alkaline 
secretions,  and,  lastly,  the  avoidance  of  irritating  the  ulcer  by  the 
passage  of  food  over  its  sensitive  surface. 

Ulcer  of  the  Duodenum. — Chronic  ulcer  of  the  duodenum  should 
be  classed  with  gastric  ulcer,  and  occurs  in  the  first  '2}/2  inches 
of  the  intestine.  It  is  essentially  a  disease  of  adult  males.  In 
39  cases  which  have  come  under  our  care  at  the  operating  table, 
32  were  in  males.  In  i)roportion  to  its  frequency  it  is  even  more 
liable  to  perforation  than  gastric  ulcer,  but  also  more  frequently 
walled  oft"  because  of  its  anatomic  relations  and  its  more  fixed  posi- 
tion. In  some  instances  the  symptoms  of  chronic  duodenal  ulcer 
cannot  be  distinguished  from  gall-stone  disease,  the  location  and 
the  colics  being  strongly  suggestive  of  biliary  calculi.  On  several 
occasions  we  have  operated  for  gall-stones  and  found  duodenal 
ulcer.  The  pain  and  local  tenderness,  however,  usually  last  longer 
in  the  latter  disease.  Of  the  combined  series  of  gastric  and  duo- 
denal ulcers  which  occurred  in  our  experience,  VZ  per  cent,  were 
duodenal  and  88  per  cent,  gastric. 

Symptomatology  of  Gastric  and  Duodenal  Ulcer. — The  symptoms 
of  chronic  ulcer  are  variable,  but  the  chief  one  is  pain. — painful  di- 
gestion,— not  all  the  time,  perhaps,  nor  at  every  meal,  but  a  feeling 
of  discomfort  a  considerable  part  of  the  day,  and  at  times  severe 
cramp-like  pains,  which  in  ulcer  of  the  pylorus  may  amount  to  a 
sharp  colic.  If  the  ulcer  extends  to  the  peritoneum,  symptoms  of 
regional  peritonitis  may  come  on,  lasting  several  days  or,  more 
rarely,  leading  to  unprotected  perforation.  Points  of  perforation 
are  usually  protected,  as  shown  by  the  frequency  of  extensive  ad- 
hesions. Fortunately,  in  the  large  majority  of  cases  of  gastric  and 
duodenal  ulcer  the  secretions  are  excessively  acid,  therefore  rela- 
tively sterile,  and  general  infection  is  less  liable  to  occur  than 


2£4  WILLIAM   J.    MAYO 

further  down  the  intestinal  canal.  Vomiting  is  a  late  symptom 
and  depends  upon  a  complicating  stenosis,  in  the  majority  of 
instances.  Hemorrhage  in  appreciable  quantities  is  rare,  although 
many  anemias  depend  upon  a  continuous  small  loss  of  blood.  As 
the  majority  of  symptoms  producing  ulcers  are  in  the  pyloric  end 
of  the  stomach,  the  syndrome  of  Hartmann  is  usually  present,  that 
is,  pain,  hypersecretion,  gas,  and  indigestion.  Ulcers  in  the  body 
of  the  stomach  are  frequently  latent,  and  the  first  knowledge  of 
their  existence  may  be  a  fatal  perforation.  Welch,  in  793  cases, 
found  235  posterior,  288  lesser  curvature,  96  anterior  wall,  95 
pyloric  ring,  while  only  29  were  found  in  the  fundus  and  27  along 
the  greater  curvature.  It  is  interesting,  and  surgically  very  im- 
portant, to  note  that  in  at  least  20  per  cent,  of  cases  more  than  one 
ulcer  is  present.  A  frequent  combination  is  one  ulcer  anterior  and 
another  facing  it  on  the  posterior  wall,  or  one  or  more  ulcers  of  the 
stomach  and  one  of  the  duodenum.  In  463  autopsies  upon  cases 
with  ulcer  of  the  stomach  Brinton  found  57  cases  with  two  ulcers, 
16  with  three  or  four,  2  with  five,  and  4  with  more  than  five. 

Chronic  ulcer  is  a  disease  of  adult  life  and  is  comparatively 
rare  in  youth.  The  small,  round,  and  fissured  ulcer  is  most  fre- 
quent in  the  female,  while  the  large,  irregular  ulcer  is  more  common 
in  males.  In  2200  autopsies  Fiedler  found  that  20  per  cent,  of 
the  female  subjects  had  evidences  of  ulcer,  while  there  was  only 
1.5  per  cent,  in  male  subjects.  In  262  autopsies  of  ulcer  cases, 
Berthold  found  134  in  women  and  128  in  men.  In  793  autopsy 
findings  Welch  gave  60  per  cent,  in  women  and  40  per  cent,  in  men. 
Our  experience  agrees  closely  with  Welch's  in  somewhat  over  300 
operated  cases.  In  a  tabulated  series  of  large  chronic  irregular 
ulcers  Seymour  Taylor  gave  72  in  males  and  28  in  females.  This 
also  agrees  with  our  experience,  although  the  preponderance  of 
males  was  not  so  great. 

The  diagnosis  of  chronic  ulcer  is  essentially  clinical.  The 
history  and  the  physical  examination,  including  outlining  the 
stomach  by  air  distention,  with  the  use  of  the  stomach-tube  to  de- 
velop stagnation  or  retention,  give  the  most  important  evidence. 
The  laboratory  findings,  while  not  worthless,  are  often  contra- 


ITLCER    AM)    CANCKK    OF    STOMA(  II  22;5 

<Iicl()ry  and  mi.slciulin;^'.  In  oxer  l.>()()  casc.N  uliicli  liaxc  Ix-cii  ex- 
amined by  Graham  and  Milld,  ITS  came  to  operation.  The  only 
test  which  had  even  corroboratory  worth  was  that  higJi  values  for 
hydrochloric  acid  ar^uc  for  ulcer  and  low  values  for  cancer;  but 
even  this  is  not  to  l)e  relied  upon.  Otherwise,  the  microscopic  and 
chemical  findings,  with  the  excei)tion  of  the  occasional  presence  of 
blood,  were  i)ractically  worthless. 

It  should  not  be  forgotten  that  ulcer  of  the  j)yloric  portion  of 
the  stomach  may  form  a  well-defined  tumor,  and  the  anemia  from 
chronic  blood  loss  develop  a  cachexia  which,  with  the  tumor,  may 
give  the  appearance  of  gastric  carcinoma  in  a  hojieless  stage.  Xo 
doubt  many  of  these  patients  have  died  from  a  condition  which  was 
essentially  benign.  We  have  but  to  look  over  the  literature  to  see 
the  frequency  of  this  mistake,  a  gastro-enterostomy  permanently 
curing  a  patient  in  whom  a  supposed  malignant  tumor  with  stenosis 
j)roved  to  be  benign. 

Prognosis. — The  mortality  of  chronic  ulcer  is  given  by  Leube 
at  about  "io  per  cent.,  and  he  states  that  about  half  of  the  remainder 
will  be  cured.  Debove  and  Remond  estimate  that  25  per  cent, 
die  directly  from  the  lesion  (hemorrhage,  perforation,  and  so  forth), 
and  25  per  cent,  additional  from  complications,  such  as  tuberculosis 
induced  by  the  anemia.  In  500  cases  reported  recently  at  the 
London  Hospital  211  were  known  to  have  had  previous  attacks,  18 
per  cent,  died,  and  42  per  cent,  were  not  cured  at  the  time  of  dis- 
charge, leaving  40  per  cent,  supposed  to  have  been  cured.  There 
is  also  the  further  danger  of  cancer  grafting  upon  ulcer  base  which 
is  undoubtedly  of  frequent  occurrence,  although  years  may  have 
elapsed  between  the  ulcer  and  the  malignant  change.  In  157 
cases  of  cancer  of  the  stomach  which  came  to  operation  at  our 
hands  Graham  found  a  good  ulcer  history  in  over  GO  per  cent., 
although  perhaps  the  malignant  degeneration  developed  years 
after  the  ulcer  had  healed.  FUtterer,  Dunn,  and  many  others  also 
insist  upon  the  etiologic  importance  of  ulcer  in  cancer  of  the 
stomach. 

Surgical  Indications. — When  should  gastric  ulcer  be  considered 
surgically.^     Leube  says  that  from  four  to  five  weeks  should  be 

VOL.  I — 15 


226  WILLIAM    J.    ]MATO 

time  enough  to  cure  gastric  ulcers  which  can  be  cured  medically. 
For  those  cases  which  have  not  developed  obstructions,  it  would  be 
best  to  try  the  Leube  treatment  (rectal  feeding,  etc.)-  The  bulk  of 
these  patients  have  employed  various  forms  of  treatment,  with 
temporary  benefit,  but  they  have  finally  reached  the  chronic 
state.  Such  cases  should  be  considered  surgically,  especially  if 
secondary  complications,  such  as  obstruction,  dilatation,  adhesions, 
and  deformities,  have  developed. 

Indications  for  the  surgical  treatment  of  gastric  ulcer  can  be 
divided  into  two  distinct  classes :  first,  the  ulcer  itself ;  second,  the 
complicating  adhesions,  deformities,|  obstructions,  etc.  There  are 
clinically  three  varieties  of  gastric  ulcer:  (a)  The  mucous  erosion, 
limited  to  the  superficial  epithelium  of  the  mucous  membrane; 
(6)  the  round,  fissured  ulcer,  which  is  probably  the  most  frequent 
and  is  limited  to  the  mucous  coat,  excepting  in  perforative  cases. 
This  ulcer  has  the  distinctive  feature  that  it  cannot  often  be  located 
from  the  exterior  of  the  stomach;  sometimes  a  little  thickening 
can  be  felt  or  a  point  where  the  mucous  coat  does  not  glide  on  the 
peritoneal  and  muscular  tunics  in  the  normal  manner.  This 
variety  of  ulcer  is  often  multiple,  and  may  lead  to  embarrassment 
at  the  operating  table,  where  an  ulcer  accurately  diagnosticated 
cannot  be  demonstrated;  (c)  the  large,  irregular  ulcer,  invading 
all  the  coats  of  the  stomach  and  easily  recognizable  by  its  thickness 
and  the  milky  or  opaque  appearance  of  the  peritoneum.  This 
variety  is  often  mistaken  for  cancer,  especially  as  enlarged  lymph- 
nodes  are  to  be  found  in  the  omenta,  particularly  in  the  gastrocolic 
omentum,  as  pointed  out  by  Lund. 

The  complications  of  gastric  ulcer  are  many.  For  example, 
adhesions,  the  separation  of  which  may  give  relief,  but  is  open  to 
the  objection  that  it  leaves  the  ulcer  which  caused  the  trouble  un- 
cured,  so  that  the  adhesions  usually  reform.  Separation  of  ad- 
hesions must  be  done  most  carefully,  as  they  may  be  protecting  a 
perforation  which  it  would  be  unfortunate  to  open.  Obstructions 
usually  exist  at  the  pylorus,  but  may  occur  in  the  body  of  the  stom- 
ach, forming  an  hour-glass  contraction. 

Gastric  Drainage. — The  keynote  to  the  surgery  of  gastric  ulcer 


ULCER    AM)    ('AN(  Kit    OK    STOMACH  227 

is  drainage,  and  llie  best  place  for  this  is  to  the  left  of  the  muscular 
pyloric  portion.  There  are  four  methods  of  inducing  gastric 
drainage:  (1)  The  Heineke-Mikulicz  pyloroplasty,  which  gives 
satisfactory  ultimate  results  in  about  70  per  cent,  of  the  cases. 
This  procedure  has  the  misfortune  of  leaving  the  enlarged  opening 
at  a  high  level,  so  that  if  the  stomach  be  greatly  dilated,  the  de- 
generated muscle  nmst  elevate  the  food  to  the  high-lying  outlet 
and  also  there  may  be  firm  adhesions  binding  it  to  the  surrounding 
tissues.  (2)  Finney's  gastroduodenostomy.  This  is  a  most  ex- 
cellent operation,  giving  a  large  opening  in  the  line  of  drainage.  It 
is  most  useful  in  narrow  strictures,  and  least  successful  in  open  ulcer, 
as  the  food  must  pass  the  ulcerated  area  to  reach  the  outlet.  (3j 
Rodman's  operation.  Excision  of  the  ulcer  would  seem  to  be  indi- 
cated in  a  large  number  of  cases;  but  if  so,  it  must  be  combined 
with  gastrojejunostomy — (a)  because  there  may  be  more  than  one 
ulcer;  (h)  because  a  stricture  often  follows  at  the  site  of  incision, 
no  matter  how  made;  (c)  because  it  leaves  the  tendency  to  ulcer 
unchecked  and  new  ulcers  maj^  form.  Rodman  suggests  that  the 
most  sensible  thing  to  do  is  to  excise  the  entire  pyloric  end  of  the 
stomach, — the  so-called  ulcer-bearing  area, — closing  the  duo- 
denum and  stomach  end  permanently,  and  then  do  a  gastrojejunos- 
tomy in  the  usual  manner.  This  would  meet  all  the  objections  to 
the  excision  of  the  ulcer  and  avoid  the  possibility  of  secondary 
cancerous  change.  (4)  Gastrojejunostomy.  All  in  all,  this 
method  meets  the  indications  most  perfectly,  although  it  is  prob- 
able that  Rodman's  operation  will  be  more  often  considered  in  the 
near  future. 

Three  hundred  and  twenty-eight  operations  for  the  improve- 
ment of  gastric  drainage  have  been  performed  by  C.  H.  ]Mayo  and 
the  writer  up  to  April  1,  1904.  This  number  is  divided  as  follows: 
20  pyloroplasties,  7  secondary  operations,  no  deaths.  Finney 
gastroduodenostomy,  -10  operations,  no  secondary  operations, 
1  death.  Gastrojejunostomy,  271,  mortality  in  the  benign  series 
6  per  cent.,  with  6  per  cent,  of  secondary  operations;  of  these,  5 
were  subjected  to  Rodman's  operation.  In  the  malignant  cases 
there  was  23  per  cent,  mortality  after  gastrojejunostomy.     The 


228  WILLIAM   J.    MAYO 

posterior  operation,  made  by  means  of  the  suture  is  preferred  by 
us  for  ulcer,  reserving  the  anterior  operation  either  with  the 
Murphy  button  or  the  McGraw  Hgature  for  the  cases  of  cancer 
and  such  cases  of  benign  disease  as  present  unusual  difficulties  to 
the  posterior  operation. 

Cancer  of  the  Stomach. — Gastric  carcinoma  is  the  most  fre- 
quent form  of  cancer  in  the  human  body.  Statistics  ranging  from 
those  given  by  Welch  as  21.4  per  cent,  of  the  total,  to  Virchow,  who 
places  it  first  at  31  per  cent.,  and  Haberlin,  at  40  per  cent.,  of  the 
total  number  of  cases. 

Why  have  there  been  so  few  attempts  to  cure  these  patients  by 
the  only  known  means,  i.  e.,  a  surgical  operation.^  There  are  three 
reasons  for  this  conservatism:  first,  a  belief  that  cure  cannot  be 
accomplished;  second,  that  the  mortality  of  radical  operations  is 
almost  prohibitory;  third,  that  the  diagnosis  cannot  be  made  until 
the  case  is  hopeless.     Let  us  discuss  these  reasons  more  in  detail. 

First. — Can  cure  be  accomplished  by  operation.^  Macdonald 
found  43  cases  cured  by  operation  which  could  not  be  disputed; 
Murphy  collected  189  cases  operated  upon  radically  by  Kronlein, 
Maydl,  Rydygier,  Czerny,  Morison,  Bevan,  and  Mayo,  ^^-ith  26 
deaths.  Of  these,  17  survived  three  years — about  8  per  cent. 
This  was  reduced  to  5  per  cent,  by  recurrence  after  three  years; 
but  as  many  of  the  cases  were  alive  and  well  more  than  two  years, 
enough  of  these  cases  would,  by  the  law  of  averages,  survive  to 
bring  the  percentage  up  to  8  per  cent,  or  more.  Not  only  that,  but 
Kronlein's  statistics  demonstrated  an  average  prolongation  of  fife 
of  fourteen  months  over  the  unoperated  cases.  ^Mikulicz,  in  100 
resections,  had  an  average  duration  of  life  of  one  and  one-third 
years.  In  our  own  experience  of  43  radical  operations  for  malig- 
nant disease  of  the  stomach,  all  but  two  who  sur\dved  the  operation 
lived  beyond  the  year;  one  lived  three  years  and  seven  months, 
and  several  are  alive  and  well  more  than  two  years  after. 

Second. — Is  the  mortality  prohibitory?  The  mortality  of  the 
operation  depends  largely  upon  the  case.  In  an  early  operation 
upon  a  patient  not  materially  reduced,  the  mortaHty  wiU  not  ex- 
ceed 10  per  cent.,  and  the  average  mortality  at  this  time,  taking 


ULCER    AM)    CANCKIt    OK    STOMMll  2'2J) 

llic  ^r()()(l  and  had  cases  as  llicy  come,  is  iiol  ahovc  '■-!()  lo  '^i')  per  <('iil. 
Much  of  llie  (lau^'cr  (IcikmkIs  upon  I  lie  adhesions  to  ucij^dihoriti},' 
viscera.  Ilaherkaiil  had  a  iiioilaHlN'  of  l^i.l  jx-r  (ciil.  with  ad- 
hesions, and  ^27.')  per  cent,  without  adhesions.  Mikulicz  had  a 
mortality  of  70  per  cent,  with  adhesions  to  the  pancreas  and  '^.'i..3 
per  cent,  without  such  adhesions.  In  the  189  cases  operated  on 
by  seven  surgeons  and  quoted  by  Murphy,  the  mortality  was  only 
about  15  per  cent. 

Tliird.^Ciin  the  diagnosis  be  made  in  time  by  medical  means? 
Vi)  this  I  say,  most  emphatically,  no;  the  condition  can  be  sur- 
mised, but  not  often  dia<;iiosticated  with  certainty.  Exi)loratory 
incision  is  practically  harmless,  and  a  suspicion  of  gastric  cancer 
.should  cause  us  to  lay  the  facts  before  the  patient  and  his  friends 
and  let  them  decide  whether  the  only  sure  means  of  making  a 
diagnosis  shall  be  undertaken  or  not. 

There  are  two  points  in  the  diagnosis  to  which  I  wish  to  call 
particular  attention,  because  I  believe  that  their  significance  has 
been  exaggerated:  First,  as  to  the  presence  of  a  tumor.  It  has 
been  said  that  the  presence  of  a  tumor  marks  inoperability.  This, 
however,  is  not  true;  a  small  movable  tiimor  in  the  region  of  the 
pylorus  is  a  favorable  indication,  because,  while  cancer  does  not 
give  evidence  of  its  presence  in  an  early  stage,  the  tumor  does  give 
such  evidence  by  obstructive  symptoms  which  call  attention  to  the 
mechanical  conditions  present.  As  a  matter  of  fact,  it  is  only  those 
diseases  located  in  the  pyloric  region  which  are  amenable  to  surgical 
intervention.  This  part  of  the  stomach  is  accessible  to  palpation 
and  also  to  operative  procedures.  Pyloric  cancer,  by  its  location, 
introduces  mechanical  features  which  enable  an  early  diagnosis. 
The  pylorus  normally  is  near  the  middle  line,  rather  than  to  the 
right,  as  we  have  been  led  to  believe,  and  the  stomach  lies  in  a  much 
more  vertical  position  than  has  usually  been  pictured,  so  that  the 
pylorus  is  not  much  above  the  lowest  point  of  the  normal  stomach. 

In  our  experience,  the  larger  number  of  cases  with  symptoms  of 
gastric  cancer  in  which  no  trace  of  a  tumor  was  present  at  the 
pylorus  and  without  .symptoms  of  obstruction  have  proved  to  be 
hopeless  cases  of  cancer  of  the  body  of  the  stomach  which  gave  no 
early  symptoms. 


230  WILLIAM   J.    MAYO 

The  second  point  upon  which  I  wish  to  speak  is  that  a  labora- 
tory diagnosis  of  cancer  of  the  stomach  is  of  Httle  importance  dur- 
ing the  operable  period,  because  the  disease  is  too  slight  in  extent 
to  interfere  with  the  secretions.  When  it  does  so,  it  usually  means 
a  hopeless  involvement. 

Radical  extirpations  of  gastric  cancer  follow  modern  lines.  The 
necessity  of  removing  the  regional  lymph-structures  is  recognized 
just  as  it  is  in  cancer  of  the  breast.  The  first  great  improve- 
ment was  due  to  the  researches  of  Mikulicz,  who  showed  that  the 
blood-vessels  and  lymphatics  of  the  lesser  curvature  lay  in  the  wall 
of  the  stomach,  and  that  it  was  necessary  in  every  case  to  remove 
all  the  lesser  curvature,  even  if  the  growth  was  small  and  confined 
to  the  pylorus.  Cuneo  demonstrated  that  the  glands  of  the  greater 
curvature  were  near  the  pylorus,  and  that  the  lymph-current  of 
this  region  was  from  left  to  right,  showing  that  it  is  not  necessary 
to  be  so  radical  in  operating  on  the  greater  curvature,  especially  as 
the  blood-vessels  are  set  at  some  distance  from  the  greater  curva- 
ture to  allow  rapid  expansion  and  contraction  of  the  stomach. 
The  lymph-nodes  in  this  situation  are  set  free  from  the  gastric 
wall  with  the  blood-vessels.  As  to  the  operation:  by  tying  the 
four  blood-vessels  supplying  the  stomach  at  proper  points,  the 
extirpation  can  be  made  practically  bloodless,  much  as  in  abdom- 
inal hysterectomy.  The  duodenum  beyond  the  growth  and  the 
stomach  at  a  healthy  point  proximal  to  it  should  be  doubly  clamped, 
and  the  diseased  part  cut  out  with  the  actual  cautery  one-fourth 
inch  from  the  holding  clamps,  preventing  inoculation  of  the  cut 
surfaces  with  cancer.  The  seared  stumps  should  be  sutured  with 
catgut  at  once  before  removing  the  clamps,  thus  checking  the 
hemorrhage  and  preventing  soiling  of  the  field  from  the  otherwise 
open  viscera.  Lastly,  both  the  duodenal  and  stomach  ends  are 
buried  by  silk  or  linen  sutures  and  an  independent  gastrojejunos- 
tomy made.  Such  an  operation  in  a  case  suitable  for  extirpation 
can  be  done  in  an  hour  without  loss  of  blood  or  shock.  We  have 
made  pylorectomy  and  partial  gastrectomy  43  times,  with  7  deaths . 

Cancer  of  the  stomach  can  be  cured  without  excessive  mortality 
only  when  exploratory  operation  is  undertaken. 


THE  ASSOCIATION  OF  SURGICAL  LESIOXS  IN 
THE  UPPER  ABDOMEN* 

WILLIAM     f.    MAYO 


The  liistory  of  medical  advance  from  the  empirical  treatment 
of  symj)toms  to  scientific  expectancy  has  been  based  upon  post- 
mortem study  and  modern  research  work.  The  spirit  has  been 
fine,  although  somewhat  pessimistic.  The  great  advances  have 
been  along  the  line  of  preventive  medicine,  and  in  the  elucidation 
of  problems  connected  with  the  etiology  of  disease. 

To  a  certain  extent,  surgical  progress  has  been  made  through 
similar  channels;  the  spirit,  however,  has  been  one  of  magnificent 
optimism.  The  great  advances  in  surgery  have  come  from  the 
clinical  side,  modern  technic  having  enabled  examination  of  pri- 
mary conditions  during  hfe. 

As  a  groundwork  for  tlie  study  of  medicine  the  pathologic 
laboratory  and  autopsy  room  offer  unrivaled  advantages,  but  they 
reach  end-results  only.  Who  of  us  has  not  admired  the  precision 
with  which  a  trained  observer  makes  a  diagnosis.'  A  few  days 
later  one  visits  the  autopsy  room  and  here  observes  that  this  al- 
most clairvoyant  analysis  was  correct.  At  the  same  time,  we  must 
also  acknowledge  that  the  patient  has  not  profited;  it  means  a 
hundred  pages  of  pathology  and  two  meager  lines  of  treatment. 
ITow  many  times  do  we  observe  m  the  autopsy  revelations  that 
the  original  lesion  has  been  but  slight,  and  at  one  stage  easily 
curable,  and  the  pathology  present  largely  the  result  of  secondary 
complications  and  terminal  infections? 

*  Oration  on  Surgery  at  the  Fifty-fifth  Annual  Session  of  The  American  Med- 
ical Association  at  Atlantic  City,  .June  7  to  10,  1904.  Reprinted  from  "Jour. 
Amer.  Med.  Assoc,"  June  11,  1904. 

231 


232  WILLIAM   J.    MAYO 

The  postmortem  has  been  an  mstitution  for  years,  yet  what 
did  we  know  about  appendicitis  until  surgery  led  the  way,  or  about 
gall-stone  disease,  supposed  to  be  an  "innocent  postmortem  find- 
ing," until  operation  opened  up  the  field?  Did  knowledge  of  extra- 
uterine gestation  come  from  the  autopsy?  By  no  means.  It  was 
obtained  through  means  of  the  surgeon's  knife,  and  why?  Be- 
cause secondary  conditions  so  often  mask  the  original  lesion  at 
the  postmortem.  On  the  contrary,  our  understanding  of  acute 
conditions  causing  sudden  death  has  been  brought  about  by  post- 
mortem investigations;  for  example,  fatal  hemorrhage  and  per- 
foration placed  acute  gastric  ulcer  on  a  sound  foundation.  Not  so 
chronic  gastric  and  duodenal  ulcers  with  late  death  from  complica- 
tions, i.  e.,  cholangitis  from  gall-stone  disease,  and  chronic  pan- 
creatitis from  the  same  cause.  These  conditions  could  not  be 
correctly  studied  until  death  occurred  from  accidental  cause,  and 
real  progress  lay  dormant  until  surgery  invaded  the  field. 

From  research  work  we  have  profited  greatly;  we  are  gaining 
rapidly  by  this  means  day  by  day,  but  we  cannot  compare  the 
animal  to  the  man,  nor  can  we  always  artificially  create  similar 
conditions.  Like  the  postmortem,  it  has  its  limitations,  yet  these 
two  fundamental  methods  have  enabled  us  to  advance.  Without 
them  we  would  still  be  in  the  middle  ages.  In  the  light  of  these 
investigations  the  time  has  conie  to  view  conditions  from  a  new 
standpoint, — at  a  time  when  the  lesion  is  in  its  infancy,  while  the 
patient  may  be  benefited, — and  the  research  work  applied  to  the 
elucidation  of  living  problems. 

The  medical  man  must  haunt  the  operating  theater  as  he  has 
haunted  the  autopsy  room  and  the  laboratory.  The  times  have 
changed:  we  must  have  more  treatment  and  less  pathology.  It 
is  here  that  surgery  wins  its  triumphs.  We  should  not  forget,  how- 
ever, that  to  physicians  with  pathologic  training  we  owe  the  knowl- 
edge which  enables  us  to  approach  the  subject.  Courvoisier  was 
the  real  father  of  gall-stone  surgery.  It  was  Balzer,  Fitz,  Opie, 
and  others  who  cleared  up  the  pathology  of  pancreatitis,  and  sur- 
gery followed  their  lead.  It  is  in  the  union  of  the  internist  and 
surgeon  that  progress  is  most  rapidly  made,  and  in  the  readjust- 


SURGICAL   LESIONS    IX    UPPER    ABDOMEN  28.'$ 

inciil  (ji'  .science  the  i'(>niier  will  he  the  architect  and  the  latter  the 
master  builder.  Once  more  the  j)hy.sician  and  surgeon  will  come 
together,  and  the  mistakes  of  endeavor  in  new  fields  will  receive 
timely  correction  at  the  hands  of  the  pathologist  and  exjjerimental 
worker. 

Today  the  surgical  borderland  lies  in  the  upper  region  of  the 
abdomen,  a  locality  until  recently  considered  almost  purely  medical. 
What  are  the  reasons  for  this  invasion,  and  have  the  results  jus- 
tified the  attempt? 

Surgery  must  be  judged  on  three  grounds:  First,  the  mortality 
of  the  operation  and  the  question  whether  this  is  greater  than  the 
expectant  plan;  second,  the  permanence  of  cure  contrasted  with 
medical  treatment;  third,  the  question  of  disability,  either  intro- 
duced by  the  operation  or  the  natural  length  of  time  which  the 
healing  process  involves.  To  each  one  of  these  considerations  we 
must  answer  j-es,  and  we  can  go  still  farther  and  say  that  earlier 
operation  would  reduce  the  mortality,  increase  the  permanence  of 
cure,  and  lessen  the  disability. 

Certain  parts  of  the  body  are  so  closely  related  in  their  anatomy, 
function,  and  pathology  as  to  be  almost  necessarily  considered  as 
part  of  the  same  system.  The  generative  organs  of  women  form 
so  distinct  a  field  of  work  as  to  have  built  up  a  specialty.  Can  we 
separate  diseases  of  the  kidney  from  those  of  the  ureter,  bladder, 
and  urethra?  By  no  means.  Each  may  stand  in  an  etiologic 
relationship  to  the  others  which  cannot  be  ignored. 

In  the  upper  abdomen  we  have  attempted  to  study  the  stomach 
independent  of  the  associated  organs,  i.  e.,  the  liver  and  bile- 
passages,  the  duodenum  and  pancreas.  The  result  has  been  a 
confusion  in  diagnosis  and  treatment.  The  palm  of  a  hand  may 
cover  a  serious  lesion  of  any  one  of  these  organs,  and  that,  too.  at 
the  point  of  greatest  liability;  moreover,  any  one  of  this  group 
may  start  a  pathologic  process  which  may  extend  to  any  one  of  the 
others,  and  with  a  frequency  fulh'  as  great  as  occurs  under  similar 
conditions  in  either  the  generative  or  the  urinary  system. 

Note  the  disturbance  of  the  stomach  which  occurs  with  gall- 
stone disease;  the  adhesions  to  the  duodenum  and  the  pancreatitis. 


234  WILLIAM   J.    MAYO 

an  association  direct  as  it  is  vital.  Again,  let  me  call  attention  to 
chronic  ulc^r  of  the  stomach  with  adhesions  to  the  pancreas, 
secondary  ulcer  of  the  duodenum  adherent  to  the  bile-passages  or 
gall-bladder.  These  are  not  fanciful  pictures,  but  drawn  from 
every-day  work.  I  have  no  hesitation  in  saying  that  with  an 
operative  experience  of  over  1400  cases  of  this  description,  mistakes 
in  exact  diagnosis  are  still  common,  and  in  many  instances  un- 
avoidable. The  history  may  be  the  only  valuable  diagnostic 
resource  when  the  patient  comes  to  us,  and  we  all  know  how  un- 
reliable that  may  be.  Given  a  history  of  painful  attacks  which 
have  been  very  severe,  but  which  have  completely  ceased,  with 
tenderness  on  deep  palpation  in  the  epigastrium,  and  we  may  have 
disease  of  any  one  of  these  four  organs,  and  not  infrequently  an 
association,  either  direct  or  indirect,  of  the  pathologic  process.  If 
we  clearly  understand  the  possibilities  of  error,  we  are  better  pre- 
pared to  meet  complications  or  execute  a  change  of  front  and  ope- 
rate on  one  organ  when  another  procedure  was  planned.  In  the 
majority  of  cases  a  pathologic  diagnosis  is  possible,  and  one  can  say 
with  certainty,  "this  is  gall-stone  disease,"  or  "this  is  ulcer  of  the 
stomach";  but  in  a  considerable  minority  a  surgical  diagnosis  is 
the  best  that  can  be  made.  That  is,  we  can  say:  "In  this  locality 
is  a  diseased  process  which  requires  operative  treatment,  the  exact 
nature  of  which  must  be  determined  by  incision."  The  patient 
does  not  come  to  us  for  the  purpose  of  having  a  certain  operation 
performed,  but  seeks  relief  from  suffering  and  disability. 

Let  me  call  your  attention  to  the  anatomic  diagram,  showing 
the  nearly  vertical  position  of  the  stomach,  with  the  pylorus  in  the 
middle  line  of  the  body,  and  but  little  elevated  above  the  lowest 
point  of  the  gastric  cavity.  It  is  turned  upward  and  to  the  right 
just  enough  to  prevent  the  weight  of  the  gastric  contents  bearing 
directly  on  the  sphincter  apparatus.  The  only  portion  of  the 
duodenum  in  which  we  are  interested  is  the  four  inches  lying 
between  the  pylorus  and  the  papilla  of  the  common  duct  of  the 
liver  and  pancreas.  This  may  be  called  the  vestibule  of  the 
small  intestines.  Its  position  subjects  it  internally  to  the  perils 
of  ulcer  from  the  acid  gastric  juices  which  its  thin  tunics  but 


SURGICAL    LESIONS    IN    IPPEU    ABDOMEN  iSo 

inadequately  resist.  Externally,  its  function  is  often  interfered 
with  hy  adhesions  to  the  j,'all-l)latlder  and  bile-tract,  secondarj-  to 
gall-stone  disease.  This  unoffending  bit  of  intestine  is  so  often 
offended  against  as  to  cause  it  to  become  the  most  frecjuently  dis- 
eased portion  of  bowel  of  the  same  length.  The  remaining  eight 
inches  of  the  duodenum  is  prot^ted  by  the  alkaline  secretions  of 
the  pancreas  and  liver.  Its  fixed  position  and  peculiar  horseshoe 
shape,  with  its  delivery  point  nearly  as  high  as  its  origin,  enable  it 
mechanically  to  slow  the  ingested  material  during  the  mixing  proc- 
ess for  which  its  large  caliber  affords  accommodation. 

The  anatomy  of  the  bile-tract  is  equally  interesting,  and  es- 
pecially the  relations  of  the  common  duct  of  the  liver  to  the  pan- 
creatic duct  and  the  duodenum.  There  is  continuity  of  mucous 
surface,  each  protecting  itself  from  the  secretions  of  the  others  by 
the  mechanical  washing  effects  of  its  own  secretion,  the  joint  dis- 
charge, and  a  feeble  sphincter  apparatus  preventing  entrance  of 
the  duodenal  contents. 

Since  the  gall-bladder  furnished  the  initial  lesion  in  more  than 
one-half  of  the  diseases  of  this  series,  it  is  of  great  interest.  Like 
the  appendix,  an  obsolete  organ  of  storage  function  and  limited 
outlet,  it  gives  rise  to  a  variety  of  troubles,  which  we  are  only  of 
late  beginning  to  appreciate.  The  gall-bladder  has  a  capacity  of 
about  an  ounce,  and  as  we  find  almost  universally,  in  organs  of 
storage  function,  the  neck  is  raised  shghtly  above  the  lowest  point, 
to  prevent  the  weight  of  contents  resting  directly  against  the  out- 
let. The  little  pouch  thus  formed  may  be  called  the  pelvis  of  the 
gall-bladder  (^Brewer).  It  is  here  that  the  obstructing  stone  is  so 
frequently  lodged  in  cystic  impactions.  Murphy  observes  that 
the  fundus  of  all  organs  has  but  few  lymphatics,  while  the  region 
of  the  neck  has  an  abundant  supply;  hence,  even  with  septic 
contents,  there  is  but  a  mild  reaction  when  the  pelvis  is  ob- 
structed, as  compared  with  the  startling  temperature-curves  of 
duct  stones. 

The  pancreas,  composed  of  two  originally  separate  parts,  in 
nearly  half  of  the  specimens  which  have  been  examined  has  two 
patent  ducts — that  of  ^Yirsung,  which  is  the  important  one,  uniting 


236  WILLIAM   J.    MAYO 

with  the  common  duct  of  the  hver.  The  minor  duct  of  Santorini, 
however,  has  a  possibility  of  useful  function  in  certain  diseased 
processes,  as  pointed  out  by  Opie.  The  pancreas  was  originally 
an  intraperitoneal  organ,  becoming  retroperitoneal  by  a  later  evo- 
lution (Huntington),  and  in  this  anatomic  peculiarity  Brewer  be- 
lieves lies  one  of  the  reasons  for  the  diffusion  of  fat  necrosis  result- 
ing from  acute  pancreatitis.  Mikulicz  has  called  attention  to  the 
fact  that  adhesions  to  the  pancreas  in  gastric  cancer  gave  a  mor- 
tality of  73  per  cent,  in  his  resection  cases.  Robson  also  notes 
the  pancreatic  mischief  occasioned  by  perforating  gastric  ulcer  on 
the  posterior  wall. 

The  blood-supply  of  this  group  of  organs  is  almost  entirely 
from  a  single  source  in  the  celiac  axis.  It  has  been  developed 
experimentally  that  the  severance  of  all  connections  of  the  pancreas 
excepting  its  blood-supply  does  not  check  secretion  if  food  is  placed 
in  the  gastro-intestinal  tract.  In  the  nerve-supply  from  the  pneu- 
mogastrics  and  sympathetic  ganglion  we  find  the  same  direct  rela- 
tionship involved.  If  we  study  the  function,  we  see  the  same  asso- 
ciation. The  stomach  can  be  compared  to  a  mill,  the  fundus  the 
hopper,  in  which  the  food  is  macerated  in  a  weak  solution  of  pepsin 
and  hydrochloric  acid,  and  the  muscular  pyloric  portion  the  grind- 
stones in  which  the  masses  are  broken  up  into  a  homogeneous  whole. 
The  entrance  of  food  into  the  duodenum  causes  the  outflow  of 
biliary  and  pancreatic  secretions,  the  absorption  returning  to  the 
liver  by  way  of  the  portal  vein.  This  is  so  elementary  that  you 
wonder  that  I  should  refer  to  it,  yet  the  causation  of  the  common 
surgical  lesions  lies  in  perversion  of  these  fundamental  functions 
and  is  just  as  simple.  Mechanical  injury  of  the  pyloric  portion 
and  excessive  acidity  of  the  gastric  secretions,  under  anemic  condi- 
tions, give  rise  to  ulcer  and  lie  behind  the  precancerous  lesions  which 
Ochsner  notes  are  found  in  the  history  of  cancer  of  the  stomach  in 
the  majority  of  cases.  The  acidity  of  the  gastric  secretions  renders 
the  contents  of  the  stomach,  when  turned  into  the  intestine,  rela- 
tively sterile,  but  increases  the  liability  of  ulcer  of  the  duodenum. 
The  sterility  of  the  upper  intestinal  tract  is  still  further  increased 
by  intestinal  absorption,  as  shown  by  Adami,  the  bacteria  being 


SI  ii<;n  \i,  hKsioNs  i\    i  rrKi;   ahdo.mia'  237 

picked  u|)  and  dc'slroycd  in  |)aii  l)y  llic  glands.  Many  ^('rni>  arc, 
however,  carried  to  the  li\-cr,  and  here  eitlier  annihilated  or  screened 
out  ol"  the  hl.ood  in  the  portal  \('in  and  discliar^'ed  with  the  Itile. 
We  iniist  h)ok  on  the  hile  as  ai\\a\s  contaiiiinfi  a  few  bacteria,  and 
it  is  pr()l)ahl\-  this  alttMiiiatcd  infection  of  l)ile  retained  in  the  <j;all- 
hhuhler  which  <;ives  rise  lo  ji,all-stone  (hsease,  which  in  Inni  i-«  the 
chief  factor  in  the  prodnction  of  <hict  iidhinnnation  of  Itotli  the 
liver  and  the  i)ancreas. 

These  considerations,  taken  in  conjunction  with  the  enihryo- 
h)uic  oriii'in,  justify  the  grouping  of  the  nurgical  Icsidhs  of  the  upper 
(liye.stlre  tract,  and  enable  the  diagnostician  to  associate  the  symj)- 
tonis  and  the  surgeon  to  direct  his  attention,  not  to  one,  but  to  the 
entire,  group  of  organs.  The  burden  of  proof  lies  with  the  prac- 
titioner, not  only  to  demonstrate  that  the  disease  rests  in  one  organ, 
but  to  differentiate  and  show  that  no  other  is  involved. 

The  art  of  the  diagnostician  lies  in  tiie  proper  valuation  of  the 
signs  and  symptoms  of  disease  in  organs  of  associated  function 
and  pathology.  The  instinct  which  seems  to  lead  some  men  to  a 
correct  conclusion,  by  a  mental  process  they  could  not  themselves 
analyze,  usually  depends  on  a  few  things,  the  immaterial  or  in- 
cojiclusive  evidence  being  unconsciously  discarded.  For  example, 
note  the  value  of  the  colic  in  the  diagnosis  of  gall-stones.  The 
typical  attack  conies  on  and  stops  abruptly,  is  relieved  by  vomiting 
or  a  feeling  of  movement  of  gas,  is  irregular  in  time  in  regard  to 
food,  is  not  accompanied  by  temi)erature  or  pulse  elevation,  and 
leaves  the  patients  able  to  attend  to  their  duties  almost  immedi- 
ately after  cessation  of  pain.  While  the  pain  lasts  it  is  excruciating, 
felt  in  its  greatest  intensity  in  the  epigastrium,  radiating  upward 
behind  the  sternum  and  into  the  back.  The  distress  penetrates 
to  the  right  side,  but  occasionally  to  the  left,  and  lasts  from  a  few 
minutes  to  six  or  eight  hours.  When  the  patient  comes  to  the 
physician,  it  may  have  been  years  since  the  typical  attacks,  which 
may  have  been  forgotten,  the  present  trouble  comi)lained  of  being 
pain,  digestive  disturbance,  and  tenderness  on  deep  pressure  over 
the  gall-bladder  region.  The  history  of  the  early  attack  is  worth 
more  than  the  physical  examination  in  many  cases.     Compare  it 


238  WILLIAM   J.    AL\YO 

with  the  pain  in  gastric  or  duodenal  ulcer,  which  may  be  just  as 
severe,  but  lasts  a  day  or  two  longer,  especially  when  due  to  re- 
gional peritonitis,  and  accompanied  by  gastric  symptoms  and 
local  tenderness.  The  patient  diets,  which  means  he  reduces  his 
food-supply.  The  symptoms  last  for  some  days  or  weeks,  and  the 
interval  of  apparent  cure  gives  some  weeks  or  months  of  com- 
parative health. 

In  this  group  of  cases  acute  perforations  of  the  organs  are  rela- 
tively common  and  give  rise  to  symptoms  which  would  be  recog- 
nized at  once  if  they  occurred  in  the  region  of  the  appendix,  but, 
occurring  in  the  upper  abdomen,  they  too  often  go  to  a  fatal  issue 
unoperated.  The  initial  symptoms  are  remarkably  alike,  whether 
of  the  gall-bladder,  the  duodenum,  stomach,  or  acute  perforation 
of  the  pancreas  with  fat  necrosis.  The  onset  is  essentially  the 
same  in  each.  Sudden  extreme  epigastric  pain,  with  collapse, 
ushers  in  the  attack,  and  muscular  rigidity,  as  a  rule,  comes  on 
early.  The  diagnosis  of  perforation,  if  we  are  on  our  guard,  is  easy, 
although  it  may  be  difficult  to  say  which  organ  is  affected;  but 
this  does  not  make  any  difference.  The  vital  consideration  is  that 
it  has  happened,  and  immediate  operation  must  be  performed. 

In  811  operations  on  the  gall-bladder  and  bile-tract  we  had  4 
acute  perforations  of  the  gall-bladder,  with  but  1  recovery,  al- 
though the  average  mortality  in  the  benign  series  was  but  4.47  per 
cent.  In  45  operations  for  duodenal  ulcer  4  acute  perforations 
occurred,  with  2  recoveries,  while  in  the  41  operations  for  subacute 
and  chronic  ulcer  there  was  only  1  death.  In  469  operations  on 
the  stomach  5  perforations  occurred,  with  2  deaths.  In  32  opera- 
tions for  diseases  of  the  pancreas  there  was  only  1  operation  for 
acute  pancreatitis  and  fat  necrosis,  with  recovery.  This  gives  14 
cases  of  acute  perforation,  with  a  mortality  of  50  per  cent.,  and 
why?  Because  the  operation  was  usually  too  late.  The  death- 
rate  in  over  1150  operations  for  subacute  and  chronic  benign  condi- 
tions of  this  group  of  organs  averaged  a  little  less  than  5  per  cent., 
counting  as  a  death  from  operation  any  patient  dying  in  the  hos- 
pital without  regard  to  cause  or  time  elapsed  between  the  operation 
and  the  fatal  issue.     If  we  add  to  this  mortality  of  50  per  cent,  in 


Fig.  20.— Showing'  the  rc!;iticins  of  tlx-  liver,  pall-bladder  and  bilc-fluct  to  the  stomach,  duodenum. 

and  pancreas. 


SURGICAL   LESIONS    IN    UPPER   ABDOMEN  2S!) 

opcriilions  for  acute  perforation  the  cases  seen  in  a  moribund  con- 
dition beyond  even  attempt  at  relief,  and  the  still  larger  number  in 
vvliich  death  occurs  without  an  antemorteni  diagnosis,  we  get  some 
idea  of  the  ai)})alling  nature  of  the  disaster.  To  be  successful, 
operation  nuist  be  immediate;  the  condition  is  as  imperative  as 
hemorrhage  from  an  artery  of  the  third  class.  Few  patients  re- 
cover who  are  operated  on  later  than  ten  hours  after  perforation. 

The  conditions  simulating  i)erforation  in  the  upper  abdomen, 
such  as  thrombosis  of  the  mesenteric  or  splenic  vessels,  diaphrag- 
matic and  duodenal  hernia  with  strangulation,  and  so  forth,  arc 
rare,  and  likewise  call  for  early  operation. 

As  a  rule,  the  history  and  location  of  the  early  acute  pain  will 
furnish  evidence  as  to  the  origin  of  the  trouble.  Preceding  per- 
foration of  the  gall-bladder  there  are  often  symptoms  of  several 
days'  duration,  with  a  history  of  gall-stones.  The  acute  pain 
occurs  in  the  gall-bladder  region.  Early  drainage  with  removal  of 
the  gall-bladder  should  give  a  mortality  of  not  to  exceed  10  per 
cent. 

Duodenal  perforation  usually  occurs  in  cases  of  chronic  ulcer 
with  years  of  symptoms  preceding;  but  the  immediate  onset  is  ex- 
ceedingly acute,  and  not  ushered  in  by  a  few  days  or  hours  of  pro- 
dromata,  as  is  often  the  case  with  the  gall-bladder.  The  location 
of  the  early  pain  is  just  to  the  right  of  the  median  line.  The  liquids 
gravitate  at  once  to  the  appendiceal  region  and  simulate  perforated 
appendix.  The  rapid  diffusion  of  escaping  contents  is  fatal  to 
delay.  Operation  for  acute  perforation  of  the  duodenum  is  rarely 
successful  after  eight  hours.  Suture  of  the  perforation  with  supra- 
pubic pelvic  drainage  and  after-treatment  in  the  sitting  posture 
(exaggerated  Fowler's)  in  early  cases  should  give  80  per  cent,  or 
more  of  recoveries. 

Gastric  perforations  occur  on  the  anterior  wall,  according  to 
Brunner,  7  times  to  1  posterior,  and  near  the  cardiac  end  5  times 
to  3  times  in  the  pyloric  portion,  and  near  the  lesser  curvature  l'2'i 
times  to  16  times  near  the  greater  curvature.  The  initial  pain  is 
usually  to  the  left  of  the  median  line,  and  early  diffusion  of  fluids 
is  to  be  expected.     Only  10  per  cent,  occur  without  previous  synij)- 


240  WILLIAM   J.    MAYO 

toms  of  chronic  ulcer,  the  results  of  operation  being  in  direct 
ratio  to  the  amount  of  gastric  contents  and  the  length  of  time  which 
has  elapsed.     The  treatment  is  similar  to  that  for  duodenal  ulcer. 

The  term  perforation  of  the  pancreas  from  inflammation  with 
resulting  fat  necrosis  is  a  purely  pictorial  expression,  and  not  a 
pathologic  entity  in  the  sense  the  word  is  used  in  the  preceding  re- 
marks, yet  it  conveys  the  idea  and  calls  attention  to  the  value  of 
peritoneal  drainage  in  its  treatment,  as  shown  by  Woolsey.  The 
symptoms  are  sudden  pain  in  the  epigastrium,  collapse,  and  early 
extreme  distention  of  the  abdomen.  On  opening  the  peritoneal 
cavity  free  fluid,  often  of  a  hemorrhagic  character,  is  evacuated. 
The  little  fatty  masses  in  every  direction  and  the  enlarged  pancreas 
call  attention  to  the  source  of  the  trouble.  This  particular  phase 
of  acute  pancreatitis  cannot  be  separated  from  the  hemorrhagic 
type  in  which  treatment  is  as  yet  in  an  unsettled  state.  Those 
interested  in  this  question  will  find  a  mine  of  information  ia  the 
Hunterian  lectures  for  1904  by  Mayo  Robson. 

The  group  of  acute  perforations  gives  an  unsatisfactory  mor- 
tality, with  a  prolonged  period  of  disability  from  drainage,  and 
without  a  certainty  of  permanent  cure  of  previous  underlying 
conditions.  This,  however,  will  not  continue  long.  Like  acute 
gangrenous  appendicitis,  the  condition  will  be  recognized  early, 
with  corresponding  improvement  in  results. 

The  diagnosis  of  the  chronic  infective  lesions  of  the  organs  of 
this  group  is  in  a  far  more  satisfactory  condition.  The  general 
mortality  of  gall-stone  operations  is  not  above  5  per  cent.,  taking 
the  cases  as  they  come,  but  even  this  is  too  high.  Grouping  the 
cases  in  which  the  entire  process  is  limited  to  the  gall-bladder,  the 
mortality  is  from  1  to  2  per  cent.,  and  depends  to  a  large  extent 
on  the  general  condition  of  the  patient.  Secondary  complications, 
chiefly  those  which  involve  the  hepatic  and  common  ducts,  with 
resultant  cholangitis,  pancreatitis,  and  so  forth,  are  responsible 
for  the  death-rate.  As  practically  all  the  patients  have  symptoms 
on  which  a  diagnosis  could  be  based  previous  to  the  complications, 
it  will  not  be  long  before  early  operation  on  patients  otherwise  in 
good  health  will  be  the  rule,  as  it  is  now  in  chronic  and  relapsing 


SI  iu;i(  AL    LESIONS    I\    UPPER    ABDOMEX  241 

ai)i)oii(licitis.  Xot  only  will  the  mortality  })c  thereby  reduced, 
l)ul  the  disjihility  will  likewise  he  lessened.  The  average  stay  in 
I  he  hospital  for  patients  with  uncomi)licated  gall-stone  disease  is 
slightly  less  than  seventeen  days;  the  convalescence  in  the  com- 
plicated duct  cases  is  prolonged  one  or  two  weeks. 

Chronic  infections  of  the  pancreas  are  usually  secondary  to 
gall-stone  disease,  and,  as  a  rule,  do  not  occur  except  where  the 
common  duct  has  been  directly  irritated  by  the  presence  of  calculi, 
although  the  consequences  may  continue  for  some  time  after  the 
passage  of  the  offending  body.  The  results  of  drainage  of  the 
gall-bladder  and  bile-ducts  are  extremely  satisfactory.  In  our 
series  of  .'J^  cases  there  were  but  2  deaths;  these  patients  had  co- 
incident suppurative  cholangitis. 

Chronic  infective  lesions  of  the  stomach  with  ulcer  as  a  type 
are  becoming  better  understood  every  day,  as  surgical  operation 
discloses  the  actual  conditions  present.  The  primary  mortality 
of  operations  for  their  relief  are  in  a  fairly  satisfactory  condition, 
but  as  to  ultimate  results  we  cannot  say  definitely.  For  the  ob- 
structive complications  the  result  of  ulcer  there  can  be  no  question 
as  to  the  relief  afforded  and  at  a  nominal  risk.  The  dilated  stom- 
ach, with  retention  or  stagnation  of  food,  suggests  drainage  opera- 
tions, with  gastrojejunostomy  as  the  type.  We  have  patients  of 
this  description  alive  and  well  more  than  twelve  years  after  opera- 
tion. 

Chronic  ulcer  without  mechanical  obstruction  gives  a  less  prom- 
ising outlook.  The  very  fact  that  there  is  normal  gastric  motility 
indicates  that  gastro-enterostomy  or  other  drainage  operation  is 
less  necessary.  Our  results  in  operations  for  this  description  of 
lesion  have  not  been  wholly  satisfactory,  and  furnish  a  consider- 
able percentage  of  secondary  operations  and  failures  to  relieve. 
Cannon's  experiments  have  shown  the  same  results.  A  gastro- 
enterostomy on  the  normal  stomach  of  an  animal  does  not  drain 
the  gastric  cavity,  even  if  placed  at  the  lowest  point.  The  gravity 
advantage  of  the  gastro-enterostomy  is  overcome  by  intra- 
abdominal tension,  and  the  food,  by  muscular  action,  is  carried  out 
of  the  pylorus  rather  than  the  artificial  opening.     The  magnificent 

VOL.  I — IG 


242  WILLIAM   J.    ]VL\YO 

showing  of  gastro-enterostomy  in  obstruction  has  led  to  the  in- 
discriminate performance  of  the  operation  in  those  cases  of  ulcer 
in  which  gastric  drainage  is  normal.  This  particular  phase  of  the 
subject  must  be  further  investigated. 

Chronic  ulcer  of  the  duodenum  is  relatively  more  common  in 
the  upper  two  inches  than  in  any  corresponding  portion  of  the 
stomach.  It  is  especially  liable  to  perforate,  although  its  sheltered 
situation  usually  leads  to  adhesive  protection.  Many  pyloric 
ulcers  will  be  found  to  have  their  origin  on  the  duodenal  side. 
Gastro-enterostomy  is  the  operation  of  choice,  as  it  diverts  the 
irritating  gastric  juices  and  food-products  from  the  sensitive  sur- 
face, thus  promoting  rapid  healing.  We  have  performed  gastro- 
jejunostomy 286  times  for  all  purposes,  with  a  mortality  of  5.5 
per  cent,  in  the  benign  series.  The  recent  improvements  in  the 
technic  of  gastro-enterostomy  have  greatly  reduced  the  mortality 
and  largely  eliminated  the  causes  of  failure  mechanically  to  relieve 
the  conditions.  Moynihan  says,  "The  surgeon  may  not  unrea- 
sonably expect  that,  from  being  a  last  resource,  gastro-enteros- 
tomy may  be  considered  as  a  method  of  treatment  worthy  of  con- 
sideration in  a  much  earlier  stage  of  chronic  ulcer  of  the  stomach." 
Excision  of  gastric  and  duodenal  ulcers  would  seem  to  be  a  wise 
procedure,  but  is  open  to  certain  strong  objections.  In  20  per 
cent,  of  cases  more  than  one  ulcer  is  present,  and  one  or  more  may 
be  undetected  or  lie  in  an  inaccessible  situation.  It  leaves  the 
ulcer  tendency  unrelieved,  and  more  ulcers  may  form.  Rodman 
has  suggested  the  removal  of  the  pyloric  or  ulcer-bearing  portion 
of  the  stomach,  with  complete  closure  of  both  duodenal  and  stom- 
ach ends  and  independent  gastrojejunostomy.  We  have  followed 
this  plan  in  5  cases  of  inveterate  ulcer  relapsing  after  gastro-enteros- 
tomy, with  good  results.  The  gastroduodenostomy  of  Finney  is  a 
most  excellent  operation,  and  we  would  predict  a  wider  field  of  use- 
fulness than  it  has  enjoyed.  We  have  performed  this  operation  46 
times,  with  1  death  and  no  relapses.  The  theoretic  objection  is 
that  in  open  ulcer  the  food  must  pass  the  ulcerated  area  before 
reaching  the  widened  pylorus,  and  obstruction  has  no  part  in  the 
production  of  ulcer,  as  is  shown  by  the  development  of  duodenal 


SURGICAL   LESIONS    IX    UPPER    ABDOMEN  243 

ulcers.  l*yloroi>la.sly  must  be  discarded.  W  liilc  \\c  had  no  deaths 
in  20  operations,  we  liad  7  reUipses. 

In  calling  attention  to  the  inali^'nanl  di.sea.ses  of  this  grouj)  of 
or^'ans  the  writer  would  enij)hasi/,c  the  possil)ilities  of  cure  hy 
means  of  operation.  In  the  gall-bladder  we  found  that  4  per  cent, 
of  cases  at  the  operating-table  had  malignant  disease,  and  all  the.se 
cases  had  gall-stones  present  or  evidence  that  they  had  been  present 
at  one  time. 

Since  it  has  become  the  practice  to  remove  all  thick-walled 
gall-bladders  as  useless  and  a  possible  source  of  future  trouble,  many 
cases  of  malignant  disease  in  an  early  stage  have  in  this  way,  as 
one  might  say,  been  accidentally  cured.  We  have  met  several 
such  instances. 

Cancer  of  the  stomach  is  the  most  common  type  of  malignant 
disease  in  the  human  body,  constituting  one-fourth  to  one-third  of 
the  total  number.  The  radical  treatment  of  gastric  carcinoma  is 
now  on  assured  ground,  with  a  mortality  of  10  per  cent.,  or  less  in 
favorable  cases,  to  20  per  cent,  in  late  but  still  operable  cases. 
The  only  necessary  factor  to  insure  success  is  an  early  diagnosis, 
and  this  must  be  on  clinical  grounds,  supplemented  by  early  ex- 
ploratory incision.  In  46  gastric  resections  for  pyloric  cancer  we 
had  7  deaths. 

The  profession  may  well  .look  upon  the  surgical  achievements 
in  this  new  field  of  w^ork  with  pardonable  pride.  That  there  are 
many  shortcomings  must  be  admitted,  but  in  the  history  of  surgery 
there  has  never  been  a  territory  opened  up  with  equal  rapidity,  nor 
one  in  which  the  physician  and  surgeon  have  worked  together  in 
such  harmony  for  the  common  good. 


DUODENAL  ULCER* 

A  CLINICAL  REVIEW  OF   58  OPERATED  CASES,  WITH 
SOME  REMARKS  ON  GASTROJEJUNOSTOMY 

WILLIAM    J.    MAYO 


Duodenal  ulcer  has  been  considered  a  rare  malady,  and  sur- 
gically it  has  not  received  the  attention  its  importance  merits. 
In  a  paper  read  before  the  American  Surgical  Association  in  May, 
1900,  Weir  analyzed  the  cases  reported  in  literature,  and  with 
observations  drawn  from  his  own  experience  placed  the  subject  on 
a  sound  foundation.  Interest  has  been  still  further  quickened  by 
a  number  of  other  investigators,  notably  Murphy  and  Brunner. 

It  has  been  stated  that  nearly  all  duodenal  ulcers  are  secondary 
to  gastric  ulcers,  and  that  the  two  are  usually  combined  in  the  one 
case.  This  has  not  been  entirely  borne  out  by  our  experience — at 
least  the  gastric  ulcer,  if  present,  has  not  been  of  the  same  grade 
and  character  as  the  duodenal.  It  is,  of  course,  possible  that  a 
round  or  fissured  ulcer  of  the  stomach  might  have  existed  without 
recognition  from  the  exterior  of  the  stomach-wall. 

Based  on  the  same  examination,  in  10  out  of  our  58  cases  of 
duodenal  ulcers  there  was  a  separate  distinct  ulcer  found  upon  the 
gastric  wall.  In  18  cases  the  pylorus  was  involved  by  a  lateral 
extension  of  the  duodenal  ulcer,  making  28  out  of  58,  or  about  50 
per  cent.  In  100  cases  of  chronic  gastric  and  duodenal  ulcers 
recently  reported  by  Moynihan,t  22  involved  the  duodenum,  in 
9  the  lesion  was  confined  to  the  duodenum,  and  in  13,  separate  and 
distinct  ulcers  existed  upon  both  gastric  and  duodenal  walls.     Up 

*  Reprinted  from  "Annals  of  Surgery,"  December,  1904. 
t"  Annals  of  Surgery,"  May,  1904. 
244 


DIOOKNAL    I  l.CKIt  245 

to  two  years  a^o  11  per  cent,  of  tlio  <::asliic  and  diKKlciial  ulcers 
wliicli  came  under  our  care  involved  tlie  duodenum,  SO  per  cent, 
t  lie  sloniacli.  I  )urinii  I  lie  past  year,  wit  li  more  careful  ohserxat  ion, 
we  find  "il  per  cent,  duodenal  alone,  or  comhined  with  pistric 
This  includes  a  numerous  j^roup  of  duodenal  ulcers  which  extend 
up  to  and  involve  the  pyloric  rintr. 

We  have  seen  a  numher  of  pyloric  iiIchms  due  to  lateral  extension 
and  involvement  of  a  i^astric  ulcer,  and  in  se\eral  of  these  the  duo- 
denum was  attacked  on  one  margin.  In  others  the  gastric  wall 
was  involved  in  a  duodenal  ulcer,  the  classification  of  gastric  or 
duodenal  being  based  upon  the  extent  of  the  involvement.  In  all 
the  cases  of  duodenal  ulcer  with  5  excej)tions  the  ulcerated  area 
was  easily  identified  as  a  thick,  opatpie  spot,  puckered  in  ap])ear- 
ance,  and  usually  covered  by  peritoneal  adhesions,  closely  resemb- 
ling the  large,  irregular  gastric  ulcer  of  Robson,  and  furthermore  it 
has  been  more  frequent  in  adult  males.  In  this  variety  of  gastric 
ulcer  Seymour  Taylor  found  72  males  to  28  females.  In  the  series 
of  58  duodenal  ulcers  herein  reported,  43  were  in  males  and  15  were 
in  females.  In  2  of  the  acute  jierforating  cases  the  ulcer  was 
clean,  clear  cut,  and  set  in  normal  tissues;  in  4  the  perforation  was 
through  a  thickened  area.  In  the  chronic  cases  a  few  completely 
surrounded  the  duodenum;  in  others  the  outlines  were  irregular 
and  of  various  sizes  and  shapes,  and  in  the  smallest  at  least  1  cm. 
in  diameter.  ^lost  of  them  involved  a  considerable  extent  of  in- 
testinal wall.  The  5  cases  without  any  appreciable  thickening  are 
of  great  interest;  of  the  2  acute  perforations  just  referred  to,  1  gave 
a  history  of  four  years'  chronic  trouble;  the  second,  of  but  two 
weeks;  no  other  ulceration  of  either  stomach  or  duodenum  could 
be  detected.  In  the  third  there  was  chronic  hemorrhage  with 
acute  exacerbation;  the  fourth  case,  in  which  gastro-cnterostomy 
was  done,  died  six  months  later  from  another  cause,  and  post- 
mortem did  not  disclose  macroscopic  evidence,  at  site  of  previous 
slight  thickening,  of  any  defect  in  the  mucous  membrane;  the 
fifth  case  was  buried  in  adhesions;  evidently  there  had  been  a 
minute  perforation,  which,  however,  could  not  be  identified.  This 
would  seem  to  indicate  that  typical  round  ulcer  of  many  years' 


246  WILLLVM   J.    ilAYO 

standing  may  exist  without  involvement  of  the  outer  coats,  and 
therefore  give  little  or  no  external  evidence  of  disease,  just  as  hap- 
pens in  the  stomach.  It  is  probable,  however,  that  most  duodenal 
ulcers  are  of  the  cicatricial  type,  and  in  our  series  there  has  been  a 
relatively  greater  tendency  to  perforate  than  in  gastric  ulcer. 
This  is  shown  by  the  peritoneal  adhesions  which  are  so  often  found, 
and  by  the  frequency  of  what  may  be  called  chronic  perforation, 
protected  by  a  mass  of  adhesions  to  the  liver,  gall-bladder,  or  gas- 
trohepatic  omentum.  These  structures  often  form  a  plaster  over 
the  perforation  and  protect  against  extravasation  of  bowel  con- 
tents. Such  chronic  perforations  were  found  in  10  of  the  58  cases. 
In  but  2  patients  did  there  appear  to  be  more  than  one  ulcer  of  the 
duodenum,  and  in  one  of  these  there  was  some  question  as  to 
whether  there  was  not  some  connection  between.  In  2  cases  of 
supposed  gall-bladder  disease  which  we  had  opened  and  drained  on 
account  of  adhesions  thought  to  be  due  to  cholecystitis  without 
stones,  no  relief  followed,  and  reoperation  became  necessary.  At 
this  time  more  careful  investigation  revealed  duodenal  ulcer. 

In  a  previous  paper  *  the  'WTiter  referred  to  4  cases  of  periduo- 
denitis of  unkno^Ti  origin,  operated  upon  for  supposed  gall-bladder 
disease,  and  in  which  the  condition  of  the  gall-bladder  did  not  bear 
out  the  presumption.  One  of  these  cases  has  since  been  reoperated 
and  duodenal  ulcer  found. 

Considering  the  known  errors  and  the  possibilities  springing 
from  a  predetermined  gastro-enterostomy  and  imperfect  examina- 
tion of  an  ulcer  situated  in  the  pyloric  region,  it  is  evident  that 
duodenal  ulcer  is  a  far  more  common  condition  than  has  been 
supposed.  The  situation  of  the  duodenum  and  the  thinness  of 
its  tissues  render  it  especially  liable  to  erosion  from  irritating  gas- 
tric secretions.  Its  sheltered  situation  fortunately  enables  pro- 
tective adhesion  in  many  cases,  while  its  limited  capacity  and 
freedom  from  obstruction  beyond  prevent  tension.  The  normal 
condition  of  relatively  sterile  contents,  especially  in  the  class  of 
cases  under  discussion,  is  also  a  favorable  circumstance. 

All  the  cases  of  duodenal  ulcer  occurred  in  the  first  two  and 
*"  Annals  of  Surgery,"  July,  1903. 


DIOOEXAL    ULCER  247 

one-half  iiulics  of  the  bowel,  entirely  above  the  entrance  of  the 
eomnion  duct,  and  therefore  in  an  acce.ssil)le  situation.  Errors 
in  examination  should  he  largely  eliminated,  and  in  all  doubtful 
eases  of  gall-stone  disease  and  gastric  ulcer  in  which  duodenal 
ulcer  is  possible  the  first  portion  of  the  duodenum  should  be  in- 
spected. For  this  reason  we  now  employ  a  longitudinal  incision, 
one  inch  to  the  right  of  the  median  line,  through  the  rectus  muscle. 
This  enables  careful  examination  of  the  duodenum,  gall-bladder, 
stomach,  and  pancreas.  If  more  space  is  needed,  Bevan's  lateral 
curved  prolongation  of  the  incision  at  either  the  upper  or  lower 
end,  or  both,  gives  additional  access  to  these  organs.  Longitudinal 
incisions  through  the  body  of  the  muscle  close  well,  and  are  more 
reliable  against  hernia  than  when  located  in  the  median  line. 

The  operative  indications  are  few.  The  causation  and  con- 
tinuation of  duodenal  ulcer  depend  on  the  irritating  gastric  secre- 
tions. These  should  be  diverted  by  a  gastro-enterostomy.  If 
acute  perforation  exists,  suture  of  the  opening  and  cleansing  of  the 
infected  area  in  the  peritoneal  cavity,  combined  with  gastro- 
enterostomy, if  the  patient's  condition  warrants  it,  best  fulfil  the 
indications.  Should  there  be  extensive  peritonitis,  pelvic  drain- 
age and  the  nearly  sitting  posture  (exaggerated  Fowler  position) 
should  be  instituted  for  a  few  days  following  operation.  For 
convenience,  the  58  operated  cases  are  divided  into  5  groups:  (1) 
Acute  perforation;  (2)  hemorrhage;  (3)  chronic  ulcer  with  gastric 
complications;  (4)  chronic  perforating  ulcer  w4th  gall-bladder  and 
liver  complications;  (5)  chronic  ulcer  requiring  operation  for  relief 
of  pain  and  distress. 

Group  1:  Acute  perforation,  6  cases,  ^  deaths.  Acute  per- 
forating ulcer  was  found  6  times,  in  all  but  one  a  complication  of 
chronic  ulcer  with  a  history  of  four  to  twenty-one  years'  standing. 
In  4  there  was  some  attempt  at  adhesions,  the  acute  perforation 
evidently  occurring  at  a  site  of  a  partially  protected  area.  In  4 
of  these  patients  there  was  a  considerable  sized  opening  found.  In 
2  already  referred  to  there  was  a  clean-cut  perforation  through 
what  was  otherwise  normal  bowel-wall.  In  4  suturing  was  easj% 
in  2  difficult  and  unsatisfactory,  requiring  gauze  packing.     One 


248  AVILLLOI   J.    :VL\YO 

of  these  patients  died  from  inanition  from  prolonged  leakage, 
although  a  gastro-enterostomy  was  done  at  the  same  time.  In 
the  other  the  gauze  pack  was  left  undisturbed  eleven  days,  and 
rectal  feeding  employed  for  five  days.  The  leakage  was  but  slight 
and  the  fistula  soon  closed.  In  4  the  suturing  held  perfectly,  but, 
unfortunately,  1  died  from  pneumonia  on  the  tenth  day.  In  this 
patient  a  gastro-enterostomy  had  also  been  done.  The  condi- 
tions were  unusually  favorable  for  an  operation,  which  was  per- 
formed within  two  hours  of  the  perforation  and  the  gastro-enteros- 
tomy was  considered  ad\'isable,  as  it  appeared  certain  that  stenosis 
would  follow,  since  it  had  existed  previously.  Superficially,  this 
would  seem  to  argue  against  gastro-enterostomy  in  acute  perfora- 
tion, but  in  each  case  the  postmortem  showed  the  gastro-enteros- 
tomy to  be  perfect. 

Group  2:  Hemorrhage,  1  case,  1  death.  There  was  a  single 
case  of  prolonged  and  repeated  hemorrhage  in  a  chronic  ulcer  of 
three  years"  duration;  during  a  two  weeks'  period  of  observation 
the  stools  showed  constant  evidence  of  blood.  There  was  a  single 
hematemesis.  The  ulcer  was  easily  recognized  as  a  little,  thick- 
ened patch  of  otherwise  normal  bowel-wall,  and  was  excised  with 
pyloroplastic  enlargement.  The  man  was  markedly  anemic  and 
a  poor  subject  for  anything  but  a  forced  operation.  Valuable 
time  had  been  lost  in  attempting  to  build  him  up.  Death  from 
pneumonia  occurred  on  the  fifth  day. 

Group  3:  Duodenal  ulcers  with  gastric  complication,  28  cases, 
1  death.  Chronic  ulcer  with  compHcations  from  interference  with 
gastric  drainage  was  the  most  frequent  form  met,  and  gastro-en- 
terostomy was  performed,  with  recovery  in  each  instance  except 
one,  in  which  acute  obstruction  of  the  transverse  colon  followed 
anterior  gastro-enterostomy.  At  postmortem  a  long  prolapsed 
transverse  colon  was  found  hanging  over  the  jejunal  loop  as  it 
would  over  a  clothes-line.  The  symptoms  were  not  acute  until  a 
few  hours  after  death.     Operation  should  have  been  done. 

Group  4-'  Duodenal  ulcer  with  gall-bladder  and  liver  complica- 
tions, 11  cases,  1  reoperation,  no  deaths.  In  this  series  gastro- 
enterostomy was  performed  in  7  cases,  with  successful   outcome. 


DUODENAL    VlAKli  24!) 

In  4  cases  plastic  ojjcralioii  was  rcs(jrtc(l  to,  with  or  \vitli(jut  ex- 
cision of  the  nicer.  In  ii  ji  mocHHed  pyloroplasty,  1  after  the  plan 
of  Heineke-Mikulicz  with  a  poor  resnlt,  a  secondary  gastro-enter- 
ostoniy  heinff  re(jiiire(l  within  three  months,  the  other  2  after  tin- 
plan  of  Kiiirie>-,  with  snccess.  In  the  tliird  the  (Inodeinini,  at  a 
point  2  inches  from  (he  pylorus,  was  acutely  flexed  upon  itself  hy 
adhesions  to  the  liver,  due  to  a  closed  adherent  perforation.  This 
made  it  possible  to  do  a  plastic  operation  upon  the  first  portion  of 
the  duodenum  without  disturbing  the  adhesion. 

Group  5:  Thirteen  cases,  no  deaths.  In  this  small  series  there 
were  sym{)toms  calling  for  operation  which  did  not  involve  the 
stomach  or  gall-bladder,  and  further  emphasized  the  fact  that 
it  was  usually  the  complication  which  hastened  operation.  In 
practically  all  these  cases  adhesions  marked  prev^ious  attacks  of 
regional  peritonitis.  Gastro-enterostomy  was  performed  in  each, 
with  good  results. 

To  recapitulate,  there  were  59  operations  in  58  cases  Of 
these,  7  were  for  acute  conditions  developing,  with  one  exception, 
upon  chronic  ulcer,  with  3  deaths.  Fifty-one  operations  for  chronic 
conditions,  with  1  death. 

At  the  present  time  posterior  gastro-enterostomy  would  appear 
to  be  the  operation  of  choice  in  the  chronic  cases,  but  the  last  word 
has  not  yet  been  said.  The  time  elapsed  since  operation  in  the 
majority  of  the  cases  herein  reported  suggests  the  possibility  of 
further  sequelte,  particularly  in  those  cases  in  which  there  is  no 
obstruction,  and  in  which  experience  has  taught  us  that  at  least 
partial  closure  of  the  gastro-enterostomy  opening  may  take  ])lace. 
It  is  almost  certain  that  even  with  a  large  gastro-enterostomy  the 
food  will  pass  out  by  preference  through  an  unobstructed  pylorus 
by  muscular  action,  the  apparent  gravity  advantage  of  a  low-jioint 
gastro-enterostomy  being  equalized  by  intra-abdominal  tension. 
Gastro-enterostomy  performed  for  gastric  ulcer  is  open  to  the  same 
objection  if  there  be  no  stenosis.  For  this  reason,  when  the  ulcer 
does  not  cause  at  least  partial  obstruction,  it  may  be  necessary 
artificially  to  block  the  pyloric  outlet. 

An   occasional    complication    following   gastro-enterostomy    is 


250  WILLIAM   J.    MAYO 

bile  regurgitation  into  the  stomach.  Acute  vicious  circle  will  sel- 
dom be  seen  if  the  opening  be  made  at  the  bottom  of  the  gastric 
cavity.  We  had  but  one  case  in  316  gastrojejunostomies  (exclud- 
ing our  first  14  cases),  and  that  one  in  a  patient  eighty  years  old. 
Chronic  bile  regurgitation  is  a  more  frequent  condition,  beginning, 
as  Ochsner  points  out,  within  three  months,  if  at  all,  although  it 
may  be  a  year  or  more  before  it  becomes  troublesome. 

Carle  and  Fantino  have  shown  that  a  little  bile  is  to  be  found 
in  the  stomach  at  times  in  nearly  all  cases  after  gastrojejunostomy, 
and  state  that  it  does  no  harm.  We  have  had  a  number  of  pa- 
tients complain  bitterly  of  the  distress  occasioned.  As  a  rule,  the 
food  passes  out  quickly,  but  there  will  be  attacks  of  biliary  regur- 
gitation at  intervals  of  days  or  weeks.  We  have  observed  this 
phenomenon  after  the  various  methods  of  operation,  and  have  been 
compelled  to  reoperate  a  number  of  times  to  check  the  disturbance. 
If  the  patient  is  in  good  general  condition,  we  now  perform  a 
posterior  suture  gastrojejunostomy  with  a  nine-  or  ten-inch  loop, 
after  the  clamp  method  introduced  into  this  country  by  Moyni- 
han.*  Four  inches  below  the  completed  gastrojejunostomy  an 
entero-anastomosis  with  suture  between  the  two  limbs  of  the 
bowel  is  made,  using  the  holding  clamps.  This  adds  ten  minutes 
to  the  operation.  A  medium  Murphy  button  is  preferred  by 
many  surgeons  for  making  the  entero-anastomosis.  To  do  this, 
the  intestinal  clamp  is  removed  after  the  two  posterior  rows  of 
sutures  are  introduced  in  the  gastrojejunostomy,  and  half  the 
button  passed  down  inside  each  limb  through  the  incised  jejunum 
to  a  point  previously  marked  with  the  knife.  The  intestine  is 
nicked,  and  the  proper  part  of  the  button  forced  through  and  junc- 
ture made  without  a  puckering  suture  (Weir).  This  adds  about 
three  minutes  to  the  time. 

A  few  mattress  sutures  should  be  placed  as  a  protection  about 
the  button  if  it  is  employed.  The  only  patient  lost  in  the  last  61 
gastrojejunostomies  at  St.  Mary's  Hospital  was  one  in  which  the 
button  union  gave  way  suddenly  on  the  sixth  day,  the  patient 
having  no  bad  symptoms  up  to  that  time.  Secondary  laparotomy 
*"  Transactions  of  American  Surgical  Association,"  1903. 


WJ.MAyo. 


Fig.  21. — Ulcer  of  duodenum.     Pylorus  blocked  by  infolding  method  A.     Sutures  in  place,  but  not 
tied.     !\Iethods  B  and  C  at  points  marked  X  X- 


\''iJU\\yo 


Fig.  22. — Posterior  gastro-enterostomy  with  entero-anastomosis  and  infolding;  sutures  placed 
for  obliterating  intestinal  interspace.  X  marks  site  of  silver-wire  constriction  or  complete  division. 
Note  that  the  drawing  shows  stomach  and  colon  drawn  outward  and  upward  as  in  actual  operation. 
Replacement  of  viscera  reverses  position  and  brings  intestinal  opening  at  the  bottom  of  gastric  cavity. 


1)1  OIJKNAI.    ru'Kit  2.51 

was  pcrforiiic'd  ten  hours  hiler,  huL  Ihc  piilicut  dit-d.  Alter  coiii- 
pletinj:;  the  l)uttori  cntero-anastomosis  the  gastrojejunostomy  is 
finished  in  the. usual  manner,  and  the  opened  mesocolon  all  ached  to 
the  jjosterior  wall  of  the  stoniaeh  in  several  places. 

To  prevent  hile  arising  to  the  level  of  the  stoniaeh,  and  also 
to  cause  the  food  always  to  pass  out  the  efferent  bowel,  the  afferent 
intestine  between  the  entero-anastomosis  and  the  gastrojejunos- 
tomy should  be  closed  in  one  of  three  ways: 

Method  A:  Infolding  may  be  practised  after  the  plan  of  Scott- 
Matolli,  a  continuous  linen  or  silk  suture  an  inch  and  a  half  in 
length  turns  the  periphery  of  the  intestine  into  the  lumen  (Fig.  22). 

Method  B:  Fowler  accomplishes  the  same  result  by  passing  a 
No.  20  silver  wire  twice  about  the  afferent  loop  at  point  X  (Fig. 
22),  and  twisting  tight  enough  to  obstruct  without  injury  to  the 
circulation,  the  twisted  ends  of  the  wire  being  turned  closely  into 
the  wire  loop.*  Methods  A  and  B  prolong  the  operation  about 
three  minutes. 

Method  C:  We  have  in  some  secondary  operations  completely 
divided  the  afferent  intestine  at  point  X  (Fig.  22),  closing  both  in- 
testinal ends  by  a  circular  suture  (Doyen),  making  the  separation 
absolute;  operation  prolonged  five  to  eight  minutes.  In  all  cases 
the  open  space  between  the  two  limbs  of  the  intestinal  loop  should 
be  partially  closed  by  a  few  sutures  at  its  lower  part  to  prevent  a 
coil  of  bowel  herniating  into  the  opening  (Fig.  22). 

A  comparison  shows  the  infolding  method  to  be  the  easiest, 
but  Crile  had  a  case  in  which,  after  a  time,  the  infolded  intestine 
straightened  out  and  required  another  operation.  The  Fowler 
method  is  evidently  more  certain.  The  Doyen  operation  is,  of 
course,  sure,  but  takes  a  little  more  time  and  adds  somewhat  to 
the  gravity  of  the  procedure.  When  finished,  however,  it  has 
all  the  advantages  of  the  "Y"  operation  of  Roux. 

Closure  of  the  pylorus  to  divert  all  the  food  to  the  gastro- 
enterostomy is  under  consideration,  and  probably  should  be  done 
in  the  large  majority  of  cases  if  there  is  no  cicatricial  obstruction. 
The  three  methods  already  described  for  closure  of  the  afferent 
*"  Transactions  of  American  Surgical  Association,"  1902. 


252  WILLIAM   J.    MAYO 

intestine  apply  equally  to  the  pylorus.  The  infolding  method  is 
shown  in  Fig.  21.  The  point  for  the  application  of  the  Fowler 
loop  or  complete  division  is  shown  by  X  (Fig.  21).  We  have 
either  infolded  or  divided  for  the  purpose  of  obstructing  the  py- 
lorus. Ochsner  has  used  the  wire  loop  a  number  of  times  success- 
fully for  this  purpose. 

The  entire  time  of  the  combined  operation  should  not  exceed 
thirty-five  to  fifty  minutes,  according  to  the  method  chosen,  in- 
cluding opening  and  closing  the  abdomen.  In  view  of  the  fact 
that  gastrojejunostomy  is  no  longer  a  last  resort,  but  an  operation 
of  choice  to  promote  comfort  and  relieve  disability,  we  must  not 
only  give  a  low  mortality-rate,  but  also  a  high  percentage  of  per- 
manent cures. 


A  REVIEW  OF  500  CASES  OF  GASTRO-ENTER- 
OSTOMY,  INCLUDING  PYLOROPLASTY, 
GASTRODUODENOSTOMY,  AND  GASTRO- 
JEJUNOSTOMY* 

WILLIAM    J.    MAYO 


The  writer  includes  in  this  series  all  the  cases  in  which  an  inci- 
sion was  made  into  both  the  intestine  and  the  stomach,  and  plastic 
union  established  between  the  two  organs,  with  the  intent  to  in- 
crease gastric  drainage.  The  term  "gastro-enterostomy"  is  used  in 
its  literal  sense — the  formation  of  an  artificial  passage  between  the 
stomach  and  intestine;  the  terms  pyloroplasty,  gastroduodenos- 
toniy,  and  gastrojejunostomy  being  used  as  expressing  more  ac- 
curately the  exact  method  employed. 

The  histories  of  the  cases  in  this  series  have  been  worked  out 
with  a  view  to  showing  the  actual  results  of  operation,  both  as  to 
mortality  and  as  to  the  percentage  of  secondary  operations.  The 
method  of  computing  the  mortality  is  to  charge  as  a  death  from 
operation  every  case  dying  in  the  hospital  without  regard  to  cause 
of  death  or  length  of  time  after  operation.  The  series  includes  pa- 
tients dying  as  long  as  three  months  after  operation,  from  coinci- 
dent chronic  nephritis,  etc.,  which  might  be  called  the  combined 
mortality  of  operation  and  disease.  This  classification  is  hard  on 
the  statistics,  but  it  eliminates  the  personal  equation.  The  statis- 
tics include  all  the  cases  which  have  been  operated  upon  in  our 
clinic  (C.  H.  and  W.  J.  Mayo)  up  to  June  20,  1905;  they  comprise 
the  early  cases  showing  a  particularly  high  mortality.  The  secon- 
dary operations  were  repeated  in  some  instances  two  to  five  times 

*  Read  before  the  American  Surgical  Association,  July,  190j.  Reprinted  from 
"Annals  of  Surgery,"  November,  1905. 

253 


254  WILLIAM   J.    MAYO  , 

before  good  results  were  obtained,  so  that  the  number  of  operations 
was  nearly  double  the  number  of  cases  reported. 

Pyloroplasty,  21  cases,  no  deaths.  Seven  secondary  operations 
(33^  per  cent.). 

Gastroduodenostomy,  Finney,  58  cases,  4  deaths  (6.9  per  cent.). 
Two  secondary  operations  (3.4  per  cent.). 

Gastrojejunostomy,  421  cases.  Benign,  307  cases,  19  deaths 
(63^2  per  cent.).  In  the  last  140  cases  there  w^ere  4  deaths,  a  mor- 
taUty  of  2y  per  cent.  The  last  80  cases  gave  but  1  death.  Malig- 
nant, 114,  with  21  deaths  (18  per  cent.).  Of  these  114  cases,  63 
were  in  connection  with  pylorectomy  and  partial  gastrectomy, 
with  8  deaths  (13  per  cent.).  The  very  unfavorable  cases  of  cancer 
obstruction  were  subjected  to  gastro-enterostomy,  so  that  this 
operation  gives  a  higher  mortality  than  radical  excision.  In  the 
last  40  gastrojejunostomies  for  malignant  disease  the  mortality 
was  8  per  cent.  In  the  421  gastrojejunostomies  there  were  21 
reoperated  cases  (5  per  cent.). 

Pyloroplasty 
The  pyloroplasty  of  Heineke-Mikulicz,  in  our  experience,  has 
but  little  risk  in  suitable  cases,  but  it  is  open  to  objection.  The 
procedure  enlarges  the  caliber  of  the  opening  as  much  in  an  upward 
direction  as  downward  in  the  line  of  drainage,  and  the  extent  to 
which  this  enlargement  can  be  carried  out  is  limited.  Following 
this  operation,  the  pylorus  is  exceedingly  prone  to  become  ad- 
herent, so  that  the  opening  remains  at  a  high  level.  The  stomach, 
if  greatly  dilated,  must  elevate  the  food  to  the  high-lying  outlet, 
and  it  frequently  happens  that  the  degenerated  muscle-fibers  are 
incapable  of  the  muscular  effort,  and,  as  a  result,  the  patient  is  not 
materially  benefited.  In  3  cases  we  fastened  the  pylorus,  after 
operation,  to  the  region  of  the  umbilicus  by  suture,  to  secure  a 
low  drainage  point,  taking  advantage  of  the  fact  that  adhesion  after 
operation  was  the  rule,  to  secure  fixation  at  a  more  favorable  situa- 
tion. These  3  cases  have  continued  in  good  health,  but  there  are 
valid  objections  to  the  procedure.  In  the  7  cases  which  came  to 
secondary  operation,  the  adhesions  were  most  marked.     Gastro- 


REVIEW    or   500    CASES    OF   GASTRO-ENTEROSTOMY  55.5 

jejunostomy  in  each  case  resulted  in  cures.  In  the  remaining  14 
cases  cure  resulted.  In  !•  ca.ses  an  ulcer  was  exci.sed  at  the  same 
time,  with  favorable  result.  Pyloroplasty  has  a  small  field  of  use- 
fulness, l)ut  in  performing  it  the  later  method  of  Mikulicz  should 
be  adopted.  The  incision  should  be  curved  downward  up'on  botli 
the  stomach  and  duodenum,  much  like  the  Finney  method,  the 
result  being  an  increased  caliber  over  pyloroplasty  as  ordinarily 
performed,  and  establishing  better  drainage  lines. 

The  principle  in  plastic  union,  established  by  pyloroplasty,  is 
one  of  the  first  importance,  and  widely  used  in  surgery.  It  is 
especially  valuable  in  choosing  the  line  of  closure  after  excising 
gastric  ulcers,  etc. 

Gastroduodenostomy 

Strictly  speaking,  this  operation  implies  a  separate  opening 
between  the  stomach  and  duodenum,  such  as  the  Kocher  operation; 
but,  as  the  method  of  Finney  more  easily  answers  the  same  purpose, 
we  have  followed  this  plan  in  the  entire  group  of  58  operations, 
with  4  deaths  and  with  2  secondary  operations  (mortality,  6.9  per 
cent.;  secondary  operations,  3.4  per  cent.).  In  the  first  46  cases 
there  was  only  1  death;  in  the  next  12  there  were  3  deaths.  It  does 
not  seem  fair  to  count  "2  of  the  deaths,  as  one  was  from  pneumonia 
after  complete  recovery  and  one  from  embolus  due  to  an  old  endo- 
carditis. We  had  an  opportunity  to  reexamine  the  operated  field 
in  3  patients  after  a  number  of  months — there  were  extensive  ad- 
hesions present  in  '2. 

Patients  should  be  carefully  selected  for  operation.  Extensive 
disease,  adhesions,  a  short  gastrohepatic  omentum,  and  especially 
the  presence  of  scar  tissue  should  be  considered  contraindications, 
since  it  is  in  these  varieties  that  gastrojejunostomy  gives  the  most 
satisfactory  results.  Two  of  the  4  deaths  were  due  to  suture 
leakage  on  account  of  tension  in  scar  tissue. 

In  open  ulcer  the  food  must  still  pass  the  ulcer  area  to  reach  the 
pylorus,  and  ulcer  does  not  depend  on  obstruction,  as  shown  by  the 
frequency  of  duodenal  ulcer  beyond  the  possibility  of  obstruction. 
Reasoning  on  this  ground,  we  would  not  expect  the  curative  results 


256  WILLIAM   J.    MAYO 

from  gastroduodenostomy  in  active  ulcer  which  we  would  get  from 
gastrojejunostomy  made  to  the  left  of  the  ulcer-bearing  area,  and 
our  experience  bears  this  out;  in  this  class  of  cases  it  has  not  given 
the  same  measure  of  relief.  The  importance  of  this  objection  is 
somewhat  minimized  by  the  fact  that  the  line  of  enlargement  is 
not  only  downward  in  the  line  of  drainage,  but  also  along  the  greater 
curvature,  which  is  seldom  involved  in  ulcer.  The  opening  can 
be  made  of  ample  size,  and  it  avoids  the  risks  habitual  to  gastro- 
jejunostomy, as  it  leaves  the  outlet  at  its  proper  situation.  In  4 
cases  we  were  able  to  combine  with  the  Finney  operation  an  exci- 
sion of  the  ulcer.  In  selected  cases  the  Finney  method  is  the  one  of 
choice. 

There  were  two  secondary  operations  in  this  group;  in  both 
individuals  bile  came  into  the  stomach,  causing  distress.  We  had 
made  the  opening  too  large,  as  shown  at  reoperation.  One  case 
had  severe  hemorrhage  from  insecure  suturing,  and  required  re- 
operation in  twenty  hours,  with  recovery. 

Gastrojejunostomy 

Gastrojejunostomy,  421  cases.  Benign,  307  cases,  19  deaths 
(6  per  cent.).  Secondary  operations,  20  (6^/2  per  cent.).  Malig- 
nant, 114  cases,  21  deaths  (19  per  cent.).  One  secondary  operation 
(0.9  per  cent.).  Of  these  operations,  63  were  made  in  connection 
with  pylorectomy  and  partial  gastrectomy. 

The  writer  has  been  greatly  interested  in  gastrojejunostomy. 
No  operation  has  conferred  greater  benefits  in  suitable  cases  than 
this  one.  Unfortunate  experience,  however,  sharpened  the  inves- 
tigation as  to  the  causes  of  deaths,  and  the  complications  which  we 
found  to  be  more  or  less  inherent  in  every  method  with  which  we 
became  acquainted.  In  all  but  3  of  the  fatal  cases  a  postmortem 
examination  as  to  the  cause  of  death  was  obtained.  Not  until 
recently  have  we  secured  a  method  which  could  be  depended  upon 
to  give  good  results  steadily  with  a  sufficiently  low  mortality  to 
justify  the  employment  of  gastrojejunostomy  in  cases  in  which 
disability,  rather  than  impending  death,  was  the  spur  to  operative 
relief. 


KKVIKW    OK    500    CASES    OF    GASTKO-P^NTEROSTOMY  257 

The  first  chiiin  to  invc.sti/:iation  comes  with  the  question.  Shall 
the  o[)eration  be  made  anterior,  after  Wiilfler,  or  posterior,  after 
von  Hacker?  Qf  the  total  number  of  cases,  126  were  anterior  and 
205  j)osterior.  The  mortality  in  the  anterior  <j:roup  was  somewhat 
over  1  per  cent,  higher  than  in  the  posterior,  but  the  jjcrcentage  of 
secondary  operations  was  greater  after  the  posterior  operation. 
The  comparison  of  mortality  is,  however,  hardly  fair  to  the  anterior 
method,  as  this  group  comprises  a  larger  number  of  the  early  oi)era- 
tions  in  which  inexperience  can  be  blamed  for  some  of  the  mis- 
fortunes. 

For  benign  disease,  the  posterior  operation  is  the  one  of  choice. 
It  is  applied  at  a  higher  point  on  the  jejunum,  and  is  unattended 
with  the  risk  pertaining  to  the  presence  of  the  loop  which  must  sur- 
round the  transverse  colon.  That  this  loop  is  of  dangerous  import 
is  shown  by  two  of  our  secondary  operations,  in  one  of  which  a 
number  of  feet  of  small  intestine  traveled  through  the  noose,  and 
in  the  second  death  was  directly  traced  to  adhesion  and  obstruction 
of  the  transverse  colon.  The  length  of  this  loop  is  from  16  to  20 
inches,  a  disadvantage  when  one  considers  the  proportionally  high 
value  of  the  upper  jejunum  in  digestion  and  absorption.  The  ante- 
rior operation  has  some  few  indications.  In  cancer  the  disturbance 
is  less,  and,  as  the  gastric  juice  has  little  acid,  the  patient  cannot  be 
expected  to  live  long  enough  to  develop  a  secondary  jejunal  ulcer. 
The  anterior  operation  is  more  liable  to  be  followed  by  contraction 
on  account  of  the  traction  weight  of  the  attached  jejunum;  a 
tliverticulum  formation  of  the  intestine  takes  place,  which  is 
followed  later  by  contraction.  This  happens  most  frequently 
following  the  use  of  the  button,  as  the  line  of  union  is  narrow  and 
it  has  less  of  a  grasp  on  the  tissues.  Contraction,  however,  is 
liable  to  occur  after  any  form  of  operation,  especially  if  the  pylorus 
be  unobstructed.  ^Yith  an  open  pylorus  nature  tends  to  close  the 
opening,  no  matter  what  the  form  of  operation,  but  the  shorter 
the  loop,  the  less  the  probability  of  contraction,  and  in  the  opera- 
tions without  a  loop  we  would  not  consider  it  a  serious  question. 
We  have  seen  a  reduction  of  one-half  take  place  three  and  five 
months,  respectively,  after  a  Moynihan  operation  on  a  9-inch  loop. 

VOL.  I — 17 


258  WILLIAM   J.    MAYO 

Vicious  circle  is  less  liable  after  the  anterior  than  after  the 
posterior  operation.  The  traction  weight  of  the  attached  intestine 
tends  to  keep  the  bowel  pulled  away  from  the  stomach,  while  after 
the  posterior  operation  there  is  a  greater  tendency  for  the  develop- 
ment of  a  kink  or  flattening  of  the  intestine  against  the  opening 
(Cannon  and  Blake).  In  spite  of  the  objections  which  we  present 
to  the  anterior  operation,  we  have  a  large  number  of  patients  ope- 
rated after  this  method  in  perfect  health  for  periods  of  time  up  to 
twelve  years. 

Angulation  and  obstruction  are  the  two  great  causes  of  re- 
gurgitant vomiting,  and,  in  our  experience,  the  short  posterior 
loop  of  from  7  to  10  inches  gave  the  greatest  number  of  such  com- 
plications. Acute  vicious  circle  occurs  very  rarely  if  the  opening 
be  placed  at  the  lowest  point  of  the  gastric  cavity;  but  a  consider- 
able number  of  patients  begin  to  have  trouble,  usually,  within  two 
or  three  months,  as  pointed  out  by  Ochsner.  This  condition  often 
increases,  and  in  from  six  months  to  a  year  gives  sufficient  annoy- 
ance to  require  a  secondary  operation. 

Murphy  Button. — Total,  157  operations.  Benign,  72  opera- 
tions, 6  deaths  (8  per  cent.);  54  anterior,  4  deaths  (8  per  cent.); 
4  reoperations  (8  per  cent.).  Eighteen  posterior,  2  deaths  (11  per 
cent.);  4  reoperations  (223^2  per  cent.).  Malignant,  85  operations, 
15  deaths  (18  per  cent.),  including  pylorectomy  and  partial  gas- 
trectomy. 

The  Murphy  button  is  least  liable  to  be  followed  by  passage  of 
bile  into  the  stomach.  While  in  position,  it  mechanically  prevents 
kinking,  and  the  character  of  the  permanent  opening  does  not 
favor  angulation.  Four  of  the  deaths  were  caused  by  pulling 
apart  of  the  attached  surfaces  in  from  six  to  ten  days  subsequent 
to  operation,  and  after  the  button  had  passed  along  the  intestine. 
We  now  always  protect  the  button  union  by  four  or  five  mattress 
sutures  of  silk,  at  intervals.  A  continuous  suture  outside  the  button 
may  prevent  its  passing  out  of  position  and  cause  it  to  lodge  and 
act  as  a  foreign  body.  If  it  were  not  for  the  frequent  retention  of 
the  button  in  the  stomach,  the  posterior  button  method,  without 
a  loop,  would  be  ideal.     Twice  we  have  had  to  remove  a  retained 


HKN'IKW    OF    .300    CASES    OF    C.'ASTUO-KNTKKOSTOMY  S.iO 

l)utt()ii  for  symptoms.  After  pyhjrectomy  and  j)artial  fjjastrcctomy 
for  cancer  we  nearly  always  emj^loy  tlie  button.  It  gives  an  im- 
mediate opening,  and  js  particularly  free  from  secondary  complica- 
tions. Jn  one  out  of  tlin>c  direct  anastomcses  hy  the  Kocher 
method,  between  tiie  duodenum  and  stomach  after  partial  gastrec- 
tomy, a  second  oi)eration  was  re(iuired  in  eight  weeks  to  relieve 
angulation  and  obstruction. 

McGraiv  Ligature. — Total,  36  operations,  lienign,  17,  ^2 
deaths  (11.7  per  cent.).  Malignant,  19,  3  deaths  (15.7  i)er 
cent.).  The  McGraw  ligature  method  anterior  has  been  very  free 
from  bile  regurgitation  and  is  exceedingly  safe.  It  can  be  placed 
in  bad  tissues  and  can  be  used  in  ])oor  subjects.  We  have  used 
this  operation  four  times  with  a  hemoglobin  of  less  than  25  per 
cent.;  once  20  and  once  24  per  cent.,  in  bleeding  ulcer,  with  re- 
covery; once  with  hemoglobin  of  24  per  cent,  in  cancer  with  acute 
obstruction,  w-ith  recovery;  once  with  hemoglobin  of  10  per  cent, 
in  cancer  with  hemorrhages  simulating  ulcer.  The  latter  patient 
was  scarcely  conscious  at  the  time  of  operation.  He  lived  three 
days,  and  although  a  stout,  heavy  rubber  cord  was  used  and  tightly 
tied,  there  was  no  sign  of  an  opening  at  the  postmortem.  It 
requires  some  vitality  to  cause  the  tissue  to  cut  through.  This 
man  did  not  have  sufficient  resistance  to  set  up  atrophy  necrosis, 
and  the  result  was  the  same  as  in  a  cadaver.  Two  cases  of  can- 
cerous obstruction  with  a  considerable  quantity  of  free  fluid  in  the 
abdomen  recovered  after  a  ligature  operation.  Tissues  which 
are  of  poor  vitality,  but  which  have  some  power  of  repair,  will  do 
so  after  a  McGraw  ligature.  The  button  might  set  up  an  uncir- 
cumscribed  slough,  or  the  suture  become  easily  infected,  if  these 
methods  were  chosen.  The  McGraw  operation,  including  open- 
ing and  closing  the  abdomen,  can  be  done  in  twelve  minutes,  with- 
out hurry.  The  disadvantages  are  that  it  should  be,  or  has  been, 
used  with  the  loop,  and,  like  any  loop  operation,  the  opening  may 
contract.  Again,  it  does  not  allow  immediate  feeding.  This  fact 
and  the  uncertainty  of  the  time  of  the  ligature  cutting  through 
render  the  method  one  for  the  occasional  rather  than  the  average 
case.     We  had  one  case  of  acute  regurgitant  vomiting  after  the 


260  WILLL\M   J.    MAYO 

McGraw  ligature,  which  was  reoperated  on  the  fourth  day.  The 
ligature  had  been  badly  placed,  and  the  opening  lay  at  one  side  of 
the  center  of  the  bowel. 

Posterior  Suture. — Total,  SSS  operations.  Mahgnant,  10, 
with  2  deaths  (20  per  cent.).  Benign,  218,  ^\dth  11  deaths  (5  per 
cent.). 

We  do  not  do  an  anterior  suture  operation.  The  increased 
risk  of  contraction  and  jejunal  ulcer  which  unavoidably  attends 
the  anterior  method  would,  mth  the  suture,  also  increase  the 
chances  of  bile  regurgitation. 

In  May,  1901,  Mr.  Robson  demonstrated  in  this  country  the 
bone  bobbin  operation,  with  the  suture  on  a  posterior  10-inch  loop. 
We  did  15  operations  by  this  method,  with  1  death. 

In  June,  1903,  we  began  using  the  method  of  jSIikuhcz,  making 
the  opening  within  3  or  4  inches  of  the  origin  of  the  jejunum,  and 
using  a  transverse  incision.  We  made  43  operations  by  this 
method,  with  4  deaths,  2  of  which  could  be  fairly  excluded.  Four 
patients  required  a  second  operation  at  our  hands,  and  to  a  large 
extent  because  we  departed  from  the  originator's  technic.  It  came 
about  in  this  way:  The  transverse  intestinal  incision  Hmits  the 
size  of  the  opening  to  one-half  the  diameter  of  the  intestine,  less 
about  one-fourth  inch  suture  line,  and  the  opening  could  seldom 
be  made  larger  than  would  admit  the  invaginated  thumb.  We 
tried  to  enlarge  this  by  encroaching  on  the  bowel,  and  caused  a 
valve  to  form  which  turned  the  bile  into  the  stomach.  These 
patients  gave  us  a  lot  of  trouble;  the  short  upper  limb  of  the  loop 
made  an  ordinary  entero-anastomosis  of  the  two  arms  of  the  bowel 
impossible.  We  finally  united  the  intestine  each  side  of  the  open- 
ing in  exactly  the  same  manner  as  the  Finney  operation  at  the  py- 
lorus. The  result  was  good.  This  was  our  first  experience  with 
the  short  proximal  loop;  the  patients  which  recovered  after  this 
method  have  remained  in  splendid  condition,  despite  the  small 
opening.  In  October,  1903,  Charles  H.  Mayo  did  two  operations 
vnih.  a  longitudinal  intestinal  opening  without  a  loop  and  as  short 
as  possible — ^practically  the  operation  we  are  doing  now.  Both 
recovered  and  remain  well. 


Kit,'.  2.5. — ShoNviriR  posterior  wall  of  stomach  drawn  lhrou);h  a  rent  in  the  transverse  mesocolon. 
Note  slight  separation  of  Rastrocolic  omentum  from  its  attachment  to  the  stomach,  permitting  anterior 
wall  of  stomach  to  appear,  and  insuring  drainage  at  lowermost  level.  Black  lines  mark  site  of  proposed 
anastomosis;   the  jejunum  shows  at  its  origin. 


Fig.  24. — Forceps  in  place  and  anastomosis  half  completed  by  suture. 


REVIEW    OF   500    CASKS    OF   CASTRO-ENTEROSTOMY  SOI 

III  the  siiiiiincr  of  1!)0.'{  Mr.  Moyiiiliaii  (Icmonstriitofl  to  us  tlie 
iiietliod  he  Avas  usiiif^'  with  the  clamp,  using  the  oblique;  j)osterior 
incision  of  the  stomach-wall  and  a  9-inch  looj).  The  use  of  the 
(•lamps  simplified  the  technic,  and  the  opening  <-ould  he  made  very 
large.  \Ve  made  53  operations  after  this  method,  with  3  deaths. 
The  i)rimary  results  with  the  Moynihan  operation  were  good.  Not 
a  case  of  acute  vicious  circle,  but  in  the  course  of  a  year  7  patients 
recpiired  a  second  operation  for  the  distress  caused  by  bile  regur- 
gitation, either  occasionally  in  large  quantities  or  frequently  in 
smaller  amount.  In  June,  1904,  we  began  the  operation  on  the 
Roux  principle,  doing  a  posterior  gastro-enterostomy  on  a  9-inch 
loop  with  entero-anastomosis.  The  proximal  loop  was  then  ob- 
structed— (a)  By  Scott-Matolli  suture;  (6)  Prowler's  silver  wire; 
(c)  division  of  intestine,  turning  in  both  ends  after  Doyen.  There 
were  48  of  these,  with  2  deaths.  Two  required  a  second  operation; 
in  one  the  silk  suture  in  the  longitudinal  plaiting  had  passed  into 
the  intestine.  The  infection  caused  adhesions,  angulation,  and 
bile  regurgitation.  In  the  second,  in  which  the  proximal  intestine 
had  been  divided,  the  cut  end  intussuscepted  through  the  upper 
part  of  the  lateral  anastomosis,  causing  obstruction.  This  com- 
plicated operation  was  of  too  serious  a  character  to  apply  to  every 
case,  requiring  from  forty-five  to  fifty  minutes  for  its  performance, 
and  on  January  1,  1905,  we  began  the  routine  use  of  the  posterior 
suture  operation  without  a  loop,  in  the  same  manner  employed  in 
the  two  eases  operated  upon  by  Charles  H.  Mayo  in  October,  1903. 

The  operation  of  choice  is  without  a  loop.  Fifty-six  operations, 
1  death  (1.8  per  cent.). 

This  operation  became  popularized  by  the  writings  of  Peterson, 
of  the  Heidelberg  clinic.  Czerny  used  the  method  for  years,  usually 
Avith  the  Murphy  button,  and  with  splendid  success.  At  the  time 
Peterson  brought  out  the  favorable  features  of  the  method  we  had 
practically  abandoned  the  button  for  the  suture  in  benign  disease, 
and  the  operation  could  not  be  easily  done  with  a  longitudinal 
o})ening  without  the  holding  clamps,  which  Moj'nihan  and  Little- 
field  later  popularized.  Mikulicz,  as  already  pointed  out,  was 
doing  the  operation  with  the  transverse  incision. 


262  WILLIAM   J.    MAYO 

Properly  to  appreciate  the  advantages  of  the  "no-loop" 
method,  some  physiologic  and  anatomic  facts  must  be  understood 
(Fig.  23).  The  stomach  is  not  a  bag,  but  a  muscular  organ,  and 
when  empty,  the  pylorus  is  not  far  from  the  lowest  point,  and  lies 
nearly  in  the  median  line  of  the  body.  As  the  stomach  distends, 
the  organ  becomes  more  nearly  horizontal  by  the  elongation  of  the 
greater  curvature.  The  pylorus  passes  to  the  right  of  the  median 
line,  and  relatively  passes  above  the  greater  curvature.  The  gastro- 
epiploic artery  sets  away  from  the  greater  curvature  about  three- 
fourths  of  an  inch  when  the  stomach  is  empty,  and  sends  its  gastric 
branches  upward  on  the  anterior  and  posterior  gastric  wall,  which 
it  meets  above  the  actual  line  of  the  greater  curvature.  This  ar- 
rangement of  the  blood-vessels  enables  rapid  distention  of  the 
stomach,  without  interference  with  the  blood-supply.  The  lesser 
gastric  curvature  is  more  fixed  in  its  position  and  can  be  divided 
into  two  parts :  the  perpendicular  portion,  which  drops  nearly  ver- 
tically from  the  right  margin  of  the  cardiac  orifice  (about  one  and 
one-half  inches  to  the  left  of  the  midline),  and  the  horizontal  or 
slightly  curved  portion,  which  turns  sharply  to  the  right  and  ends  at 
the  pylorus.  Ordinarily,  the  concavity  of  the  lesser  curvature  is 
from  two  to  three  inches,  the  corresponding  point  on  the  greater 
curvature  being  three  and  one-half  to  four  and  one-half  inches, 
making  the  convexity  of  the  pyloric  segment.  This  is  the  grinding 
muscular  portion  of  the  stomach,  the  part  subjected  to  the  greatest 
amount  of  traumatism,  and  over  80  per  cent,  of  all  the  lesions  for 
which  we  are  called  to  operate  are  either  in  this  part  or  in  the  first 
two  and  one-half  inches  of  the  duodenum.  The  gastrojejunal 
opening  should  be  placed  just  to  the  left  of  this  portion  of  the 
stomach  (Fig.  24) .  The  inferior  margin  of  the  gastrojejunostomy 
should  lie  at  the  greater  curvature,  on  a  line  opposite  the  juncture 
of  the  transverse  and  longitudinal  parts  of  the  lesser  curvature. 
This  is  rather  farther  to  the  right  than  has  usually  been  practised. 
The  duodenum  passes  through  the  mesocolon,  nearly  on  a  perpen- 
dicular plane  with  the  cardiac  orifice,  one  and  one-half  inches  to 
the  left  of  the  midline,  and  when  the  stomach  is  empty,  its  lower 
border  lies  nearly  on  a  line  with  the  origin  of  the  jejunum.     When 


IU;\IK\V    OF    500    C'AHF:S    ok    fJASTKO-IlNTKHOSTOMY  203 

the  gastric  ciix'ily  is  (iislcndcd  or  dilated,  it  dc.scoiids  and  covers 
this  point.  The  j)roi)er  situation  of  the  gastric  opening  should  be 
ol)Hciue  on  the  jjostcrior  wall,  hcj^inniiig  on  the  body  of  the  stomach 
between  the  lesser  and  greater  curvatures,  and  extending  flownward 
to  the  very  bottom  of  the  stomach — Moynihan's  line  (Figs.  24  and 
25).  To  insure  that  the  opening  shall  be  at  the  very  lowest  point 
at  its  right  margin,  we  slightly  separate  the  omentum  from  the 
greater  curvature,  and  pull  one-fourth  inch  of  the  anterior  wall  out 
posteriorly,  pushing  the  gastro-epiploic  vessel  out  of  the  way  (Fig. 
26). 

In  previous  contributions  to  this  subject  we  have  called  atten- 
tion to  the  changed  nature  of  the  proximal  arm  of  the  jejunal  loop 
after  gastrojejunostomy.  It  becomes  succulent  and  thick.  With 
the  loop  operation,  the  food  could  and  did  pass  into  the  proximal 
arm,  while  the  {)eristalsis  of  this  short  end  was  inefficient,  and 
herein  lay  most  of  the  difficulties.  Peterson  pointed  out  that  if 
the  jejunum  were  attached  short  without  a  loop,  it  would  require 
a  reverse  peristalsis  to  carry  food  into  the  duodenum.  Peterson's 
point  of  jejunal  election  lies  within  from  one  to  three  inches  of  the 
origin  of  the  jejunum,  varying  as  necessary  to  enable  easy  attach- 
ment to  the  stomach  (Figs.  23  and  24).  It  will  be  noted  that  the 
line  of  proposed  union  is  a  natural  one.  The  jejunum  attaches  to 
the  stomach  without  kink  or  bend  in  the  line  of  gastric  activity 
(distention  and  contraction).  The  intestine  comes  off  the  bottom 
of  the  stomach  as  though  it  were  mortised  on,  the  opening  extend- 
ing upward  and  to  the  left.  As  Cannon  and  Blake  have  experi- 
mentally j)roved,  and  we  have  clinically  demonstrated,  the  food 
will  pass  out  of  the  unobstructed  pjdorus  after  any  method  of  gastro- 
jejunostomy; with  this  method  of  operation  it  makes  little  differ- 
ence. Spasm  of  the  whole  pyloric  end  of  the  stomach,  which 
quickly  follows  ulcer  or  other  irritation,  no  longer  holds  back  the 
food  and  secretions.  The  gentle  compressing  action  of  the  cardiac 
end  is  quite  sufficient  to  turn  the  secretions  and  delayed  ingesta 
out  the  gastrojejunostomy.  Relief  of  the  pyloric  obstruction,  no 
matter  what  the  character,  permits  normal  progress.  Interruption 
of  this  calls  the  new  opening  into  use.     It  is  not  at  all  necessary  for 


264  WILLIAM   J.    ilAYO 

the  chyme  to  enter  the  duodenum  to  stimulate  pancreatic  and  bil- 
iary discharge;  this  happens  whenever  the  gastric  product  enters 
the  small  intestine  at  any  point.  In  all  the  loop  operations,  more 
or  less  of  the  jejunum,  at  its  most  important  situation,  is  thrown 
into  a  by-channel.  The  opening  of  the  common  duct  Hes  four 
inches  below  the  normal  pyloric  entrance  of  food.  This  operation 
brings  the  common  duct  opening  eight  inches  above  the  gastro- 
jejunal  food  entrance,  and  the  constant  presence  of  biliary  and  pan- 
creatic alkaline  secretions  will  certainly  render  secondary  jejunal 
ulcer  less  frequent  than  primary  duodenal  ulcer. 
To  recapitulate: 

1.  The  gastric  opening  should  be  placed  on  the  posterior  wall, 
obliquely  from  above  downward,  and  left  to  right  (Fig.  23)  (Moy- 
nihan's  line). 

2.  The  lowest  point  of  the  gastrojejunostomy  should  be  at  the 
lowest  point  of  the  stomach,  on  a  plane  perpendicular  with  the 
cardiac  orifice  (Fig.  23). 

3.  To  insure  this  effect,  the  gastric  incision  should  extend  one- 
fourth  to  one-half  of  an  inch  on  the  anterior  wall  (Nos.  1,  2,  3,  and 

4). 

4.  The  incision  in  the  intestine  should  be  longitudinal,  opposite 
the  mesentery,  and  begin  from  one  to  three  inches  from  the  origin 
of  the  jejunum,  measuring  on,  the  anterior  surface.  (Peterson's 
point  of  election,  Fig.  23.)  The  exact  distance  depends  on  the 
ease  of  attachment — as  short  as  can  be  conveniently  done  ^dthout 
tension. 

A  description  of  the  operation  is,  briefly,  as  follows:  (a)  The 
abdominal  incision  is  made  four  inches  in  length,  three-fourths 
inch  to  the  right  of  the  middle  line,  the  fibers  of  the  rectus  muscle 
being  separated.  The  lower  end  of  the  external  wound  lies  op- 
posite the  umbilicus.  This  opening  also  enable  inspection  of  the 
duodenum  and  gall-bladder  and  guards  against  hernia  when  closed. 
(b)  The  transverse  colon  is  pulled  out,  and  the  mesocolon  made 
taut  by  traction  upward  and  to  the  right,  in  this  manner  bringing 
the  jejunum  into  view  at  its  origin,  (c)  About  three  to  four 
inches  of  the   jejunum   opposite   the   mesentery  are  drawn  into 


Fig.  25  — Completed  operation  ln)ni  behind  marfjin  of  torn  mesocolon  attached  by  several  interrupted 

sutures  to  line  of  union. 


Fig.  26. — Completed  operation  from  in  front.  Anastomotic  opening  sliows  througii  as  darkened 
area  on  posterior  wall.  Note  that  it  goes  to  the  bottom  of  the  gastric  cavity  and  slightly  anterior, 
as  indicated  by  suture  line  in  the  omental  attachment. 


REVIKW    OF   oOO    CASES    OF    (JASTRO-ENTEROHTOMY  '2(!.3 

ji  sli^'lilly  ciirwd  clainp.  Tlie  liaudk-s  of  the  chiin|).s  should  he 
to  the  riglit,  to  enable  a  short  grasp  on  the  intestine.  Three- 
fourths  of  the  circumference  of  the  bowel  is  pulled  through; 
tlie  posterior  border  is  not  included,  which  prevents  entanj-de- 
ment  of  the  suture  with  the  redundant  posterior  mucous  mem- 
brane. The  holding  clamps  are  ai)plied  sufficiently  tight  to  check 
hemorrha<;c    and    prevent    extravasation  of    intestinal    contents. 

(d)  The  ligament  of  Trcitz  is  a  short  muscular  mesentery  cov- 
ered by  a  variable  [)eritoneal  fold  (too  variable  for  a  reliable  lantl- 
mark),  extending  upward  from  the  origin  of  the  jejunum  on  to  the 
mesocolon.  This  j)eritoneal  fold  lies  at  the  base  of  the  arterial 
looj)  of  the  middle  colic  artery  which  supplies  the  transverse  colon. 
The  mesocolon  is  opened  within  the  vascular  loop,  and  the  posterior 
inferior  border  of  the  stomach  pushed  through.  A  small  separation 
of  the  greater  omental  attachment  to  the  stomach  enables  the 
anterior  gastric  wall  to  be  drawn  out  posteriorly.  The  posterior 
gastric  wall  is  drawn  into  a  clamp,  with  the  handles  to  the  right, 
in  such  a  manner  as  to  expose  the  anterior  wall  at  the  base. 

(e)  The  two  clamps  are  laid  side  by  side  and  the  field  carefully 
protected  by  moist  gauze  pads.  ^Yith  fine,  celluloidal  linen  thread, 
on  a  straight  needle,  the  intestine  is  sutured  to  the  stomach  from 
left  to  right  by  a  Gushing  suture  at  least  two  and  one-half  inches. 
(/)  The  stomach  and  intestine  are  incised  one-sixth  inch  in 
front  of  the  suture  line,  and  the  redundant  mucous  membrane 
excised  flush  with  the  retracted  peritoneal  and  muscular  coats. 
With  a  No.  1  chromic  catgut  on  a  straight  needle  the  posterior  cut 
margins  of  the  entire  thickness  of  the  gastric  and  jejunal  wall  are 
united  by  a  buttonhole  suture  from  right  to  left;  at  the  extreme  left 
the  suture  changes  to  one  which  i)asses  through  all  the  coats  of  each 
side  alternately,  from  the  peritoneal  to  the  mucus,  then  directly 
back  on  the  same  side  from  the  mucus  to  the  peritoneum.  This 
acts  as  a  hemostatic  suture,  and  also  turns  the  peritoneal  coats 
into  apposition.  It  i)asses  around  the  anterior  surface  and  is  tied 
to  the  original  end,  which  has  been  left  long  for  the  jiurpose.  If 
silk  or  linen  is  used  for  this  suture,  it  may  hang  in  situ,  suppurating 
for  months,     (g)  The  clamps  are  now  removed,  and  the  linen  thread 


266  WILLIAM   J.    MAYO 

continued  around  until  it  is  tied  to  the  original  end,  firmly  catching 
the  blood-vessels  in  sight  along  the  suture  line.  The  parts  are 
carefully  cleansed  and  inspected.  If  necessary,  a  suture  or  two 
is  applied,  accurately  to  coaptate  or  to  check  the  oozing,  (h)  The 
margins  of  the  incised  mesocolon  are  now  united  to  the  suture  line 
by  three  or  four  interrupted  sutures,  and  the  parts  returned  into 
the  abdomen. 

When  the  patient  is  placed  in  bed,  a  glass  female  douche  point 
is  passed  just  above  the  internal  sphincter  ani,  attached  to  a 
gravity  bag  filled  with  one-half  strength  normal  salt  solution.  The 
elevation  should  not  be  greater  than  six  inches.  The  small  stream 
passing  into  the  rectum  is  readily  absorbed  without  irritation. 
One  or  two  quarts  are  taken  up  in  an  hour  (Murphy).  The  pa- 
tient is  then  placed  in  the  semisitting  posture.  Beginning  at  from 
sixteen  to  twenty  hours,  an  ounce  of  hot  water  is  given  every  hour; 
this  is  rapidly  increased,  and  in  thirty-six  hours  the  usual  experi- 
mentation with  liquid  feeding  is  instituted.  Rectal  feeding  is  un- 
necessary. The  operation  is,  in  all  of  its  essential  parts,  that  of 
Mr.  Moynihan. 


CHRONIC  ULCER  OF  THE  STOMACH  AND 
FIRST  PORTION  OF  THE  DUODENUM, 
WITH  ESPECIAL  REFERENCE  TO  THE 
SURGICAL  TREATMENT* 

WILLIAM    J.    MAYO 


Chronic  ulcer  of  the  stomach  is  certainly  a  more  frequent 
condition  than  clinicians  would  lead  us  to  believe.  Compare  the 
results  of  autopsy  findings  with  the  clinical  diagnosis  upon  ad- 
mission to  the  hospital,  for  example.  Take  three  hospitals  in 
Philadelphia — Blockley  Hospital,  giving  1.42  per  cent,  as  the 
result  of  autopsy  finding;  University  Hospital,  clinical  findings 
0.48  per  cent.;  Pennsylvania  Hospital,  clinical  findings  0.13  per 
cent.  (Francine).  In  other  words,  in  two  hospitals  of  exactly  the 
same  character  in  the  same  city  ulcer  is  found  clinically  nearly 
four  times  as  often  as  in  the  other,  while  both  fall  short  of  the  post- 
mortem from  3  to  11  times.  Bettman  finds  that  a  diagnosis  of 
gastric  ulcer  was  made  but  24  times  in  27,567  Cincinnati  hospital 
admissions  (0.08  per  cent.).  Howard,  in  comparative  tables, 
shows  that  New  York  city  autopsy  records  give  1.42  per  cent,  of 
gastric  ulcers,  while  the  records  of  clinical  admissions  show  only 
0.44  per  cent.  Boston  does  better:  autopsy,  1.84  per  cent.; 
cHnical,  1.28  per  cent.  Francine  says:  "I  entirely  agree  with  Dr. 
Howard's  statement  that  we  cannot  base  accurate  or  conservative 
conclusions  on  data  obtained  from  clinical  observation." 

In  10,841  autopsies  in  7  large  American  cities  (Howard)  the 
percentage  of  gastric  ulcers  was  1.32,  while  in  Ix)ndon  it  was  4.6  per 
cent.,  and  in  continental  Europe  8.54  per  cent.     Welch  gives  5 

*  Read  in  the  Section  on  Surgery  and  Anatomy  of  the  American  Medical 
Association  at  the  Fifty-sixth  Annual  Session,  July,  1905.  Reprinted  from  "Jour. 
Amer.  Med.  .\ssoc.,"  1905,  vol.  xlv. 


268  WILLLOI   J.    :^IAYO 

per  cent,  in  32,052  autopsies  in  the  Prague,  Berlin,  Breslau,  Dres- 
den, Erlangen,  and  Kiel  Hospitals.  There  are  two  explanations 
of  the  greater  apparent  frequency  of  gastric  ulcer  in  Europe  than 
in  America.  One  is  that  it  is  not  apparent,  but  real,  and  another 
that  the  pathologic  departments  of  European  cities  have  been 
permanently  estabhshed  for  a  long  time  and  postmortems  are 
obligatory,  while  until  of  late  years  the  work  in  American  cities 
has  been  under  changeable  management  and  subjected  to  a  var- 
iable personnel;  also  that  consent  of  legal  representatives  must  be 
obtained,  and  therefore  autopsies  are  relatively  much  less  frequent 
in  this  country.  As  showing  the  eflFect  of  searching  with  a  definite 
purpose,  Griinfeld,  of  Copenhagen,  found  11  per  cent,  of  gastric 
ulcers  in  1150  autopsies,  and  in  the  next  450,  examined  more  care- 
fully, found  20  per  cent. 

In  regard  to  the  relative  frequency  of  gastric  and  duodenal 
ulcers,  we  have  but  few  statistics.  Francine  found  38  cases  of 
gastric  ulcer  in  2830  autopsies,  2  duodenal,  also  2  duodenal  and 
gastric,  practically  only  10  per  cent,  of  duodenal.  As  compared 
with  surgical  findings,  this  is  too  small,  and  does  not  bear  out  the 
relative  frequency  sho'v\Ti  by  statistics  of  acute  perforations.  In 
22  cases  of  acute  perforating  ulcers  Moynihan  found  15  gastric 
and  7  duodenal.  Our  experience  with  acute  perforating  ulcer  is 
relatively  smaller  than  with  chronic  ulcer.  In  13  acute  perforat- 
ing ulcers  6  were  gastric  and  7  duodenal.  Brunner  collected  600 
cases  of  acute  perforation,  of  which  one-fourth  were  duodenal. 
He  also  showed  that  90  per  cent,  of  acute  perforating  ulcers  occur 
through  the  site  of  chronic  ulcers,  and  that  diagnostic  symptoms 
usually  exist  previous  to  perforation. 

The  duodenum  above  the  opening  of  the  common  duct  of  the 
liver  and  pancreas  is  exposed  to  the  same  ulcer-producing  causes 
that  exist  in  the  stomach,  ^\dth  the  possible  exception  of  trauma- 
tism; and  as  its  tunics  are  thinner,  it  is  even  more  readily  affected 
by  irritating  secretions  and  ingesta.  Statistics  appear  to  show  that 
ulcer  of  the  duodenum  is  a  rare  malady,  but  the  data  on  which  the 
supposition  is  based  have  been  furnished  either  by  postmortems 
or  are  the  results  of  notoriouslv  defective  clinical  examinations. 


CIIHOMC     \lAK\i    OK    STOMACH     AM)     l)l()l)i:Nr.M — SL'HC;KHY       269 

Postinortein  study  has  c-ortaiii  disa(lvanta{j;('s  due  to  influences 
wliicli  lia\('  i)erluii)s  l)C(.-onie  active  either  shortly  before  or  at  the 
time  of  death,  and  which  often  mask  lli<>  primary  lesion  and  cloud 
the  condition  as  it  existed  in  life.  Secondary  clianj^es  and  ter- 
minal infections  may  prevent  a  correct  interpretation  of  the  signs 
jind  symptoms  which  were  manifested  during  the  early  stages  of 
the  disease — the  curable  period.  This  is  shown  by  the  revelations 
of  surjfery  in  ap])ondicitis,  extra-uterine  pregnancy,  and  chole- 
lithiasis. 

The  same  potent  force  is  now  at  work  in  the  field  of  ulcer  of  the 
stomach  and  duodenum,  and  the  first  fact  which  has  been  demon- 
strated is  that  those  forms  of  ulceration  which  affect  all  the  coats 
of  the  viscera  and  which,  by  reason  of  their  large  size  and  thick, 
scar-like  appearance,  can  be  easily  demonstrated,  are  nearly  as 
common  in  the  duodenum  as  in  the  whole  of  the  stomach.  The 
postmortem  statistics  which  have  been  gathered  are  certainly 
erroneous  in  their  summing  up  as  to  the  relative  frequency  of 
gastric  and  duodenal  ulcer.  The  only  conclusion  which  one  can 
arrive  at  is  that  the  examination  was  general  and  did  not  cover 
the  duodenum  with  the  same  care  that  it  did  the  stomach.  The 
duodenum  has  received  but  little  attention  and  therefore  it  has 
not  been  subjected  to  close  scrutiny  during  general  autopsy. 

Admitting  that  clinical  observation  falls  short  of  the  autopsy 
findings,  in  what  way  do  results  of  surgical  work  compare  with  post- 
mortem records  ?  Within  fourteen  years  nearly  800  cases  of  gastric 
and  duodenal  disease  have  been  operated  in  St.  Mary's  Hospital. 
Eliminating  gastric  cancer  and  all  cases  in  which  the  necessity  for 
operation  did  not  immediately  arise  from  ulcer,  we  have  384  opera- 
tions for  gastric  ulcer  and  its  results,  and  84  operations  for  duo- 
denal ulcer,  or  about  78  per  cent,  gastric  and  22  per  cent,  duodenal; 
but  this  is  not  fair  to  the  duodenal  disease,  because  it  has  only 
been  within  a  short  time  that  we  have  recognized  duodenal  ulcers, 
and  many  of  our  earlier  cases  marked  pyloric  may  have  been  an 
extension  from  the  duodenum.  We  have  thought  it  wise  to  narrow 
the  limits  of  this  to  a  consideration  of  the  cases  in  the  last  two  and 
one-half  vears,  from  Januarv  1,  1903,  to  Julv  1,  190o,  and  also  to 


270  WILLIAM   J.    MAYO 

consider  only  the  cases  subjected  to  gastrojejunostomy,  exclud- 
ing all  of  the  ulcers  excised  or  subjected  to  Finney's  operation, 
pyloroplasty,  etc.  This  gives  us  231  cases,  119  males  and  112 
females,  of  which  158  were  gastric,  60  duodenal,  and  14  duodenal 
and  gastric ;  20  of  the  duodenal  ulcers  extended  up  to  and  involved 
the  pylorus.  In  others  words,  out  of  231  gastric  and  duodenal 
ulcers,  the  duodenum  was  involved  74  times:  55  times  in  males 
and  only  19  in  females. 

Classification  of  Gastric  and  Duodenal  Ulcers 
For  clinical  purposes  I  will  classify  all  the  ulcers  operated  on 
into  two  groups,  the  indurated  and  the  non-indurated:  First,  the 
indurated  ulcer,  which  involves  all  the  coats  of  the  organ  and  which 
usually  shows  evidences  of  cicatrization  in  some  part  of  its  extent. 
The  diseased  area  is  a  thick,  milky-white  patch,  easily  identified 
from  without  the  gastric  or  duodenal  wall.  In  the  stomach  it 
involves  the  pyloric  portion  in  the  great  majority  of  cases;  it  is 
frequently  saddle-shaped,  riding  the  lesser  curvature,  and  extend- 
ing flap-like  down  the  anterior  and  posterior  walls.  In  such  cases 
the  pyloric  portion  beyond  is  usually  thickened  and  gives  rise 
to  more  or  less  obstruction,  even  if  not  actually  involved  in  the 
ulcerative  process.  In  about  20  per  cent,  more  than  one  ulcer 
was  found.  In  the  duodenum  the  first  23^  inches  is  always  in- 
volved well  above  the  entrance  of  the  common  duct,  with  its  alka- 
line discharges,  and  the  ulcer  extends  up  to  the  pylorus  or  within  ^ 
inch  of  it.  In  only  3  instances  was  more  than  one  duodenal  ulcer 
shown.  Sixty-eight  of  the  74  duodenal  ulcers  were  of  the  indurated 
variety,  and  151  of  the  total  231  cases  of  duodenal  and  gastric 
ulcers  were  so  classified.  Of  these,  95  were  males  and  56  females. 
In  100  cases  Seymour  Taylor  found  72  males  and  28  females. 
Associated  with  this  group  of  indurated  ulcers  are  the  benign 
pyloric  obstructions  of  inflammatory  origin,  hour-glass  stomachs, 
adhesions,  and  deformities  arising  from  protected  chronic  perfora- 
tions. 

The   non-indurated   ulcer   has    also   been   termed   medical   or 
clinical,  because  although  they  give  undoubted  evidence  of  the 


W.J.Ma/o. 


\ 


\ 


V 


^'tf*^* 


Fig.  27. — Showing  forceps  passed  through  from  behind  and  grasping  anterior  gastric  wall  near  the  greater 
curvature  at  the  lowest  point.     Saddle  ulcer  of  lesser  curvature  near  pylorus. 


Fig.  28. — Posterior  wall  of  the  stomach  drawn  through  opening  torn  in  transverse  mesocolon. 
Forceps  still  marking  low  point.  Dotted  lines  on  stomach  and  Jejunum  show  situation  of  proposed 
anastomosis. 


CHRONIC     ITLCKIl    OK    STOMACH     AM)     DLODK.VUM SURGERY       271 

disease,  there  is  nolhinj,'  to  show  the  ulcer  site  from  the  exterior 
of  the  stomach  upon  exploration.  Tlie  reason  for  this  is  that  the 
lesion  involves  only  the  mucous  coat.  In  some  cases  a  little  thick- 
ening can  be  discovered  (Mikulicz),  or  a  glueinf^  of  the  mucous  to 
the  nuiscuiar  coats,  preventing  the  normal  slipping  of  one  on  the 
other  (Moynihan).  But  in  the  typical  case  prolonged  search  of 
the  interior  of  the  stomach  may  be  necessary  to  find  the  diseased 
process.  Many  individuals  have  bled  to  death  from  an  ulcer  so 
minute  that  it  could  be  found  only  with  the  microscope.  Bram- 
well  says  that  many  of  these  cases  heal  so  minutely  that  no  evi- 
dence can  be  found  at  autopsy. 

We  have  had  a  number  of  patients  come  to  operation  after  years 
of  trouble, — hemorrhages,  stagnation  and  retention  of  food,  etc., — 
who  were  cured  by  operation,  but  in  whom  no  sign  of  ulcer  could 
be  shown  on  the  exterior  of  the  stomach.  In  some  instances  we 
have  oi)ened  and  searched  the  interior  of  the  gastric  cavity  to  find 
an  ulcer  from  which  the  patient  had  bled  repeatedly,  but  we  have 
not  always  found  it.  It  is  possible,  or  indeed  probable,  that  in 
some  of  these  patients  an  indurated  ulcer  may  have  existed  in  a 
situation  not  accessible  to  palpation  or  inspection. 

Non-indurated  ulcers  are  of  two  varieties:  (a)  The  mucous 
erosion  of  Dieulafoy,  in  which  only  the  superficial  epithelial  layers 
of  the  mucous  membrane  are  involved,  and  (b)  the  typical,  round, 
peptic  and  fissure  ulcer.  'In  our  experience  the  fissure-like  ulcer 
has  been  of  frequent  occurrence.  In  one  patient  bleeding  at  the 
time  of  operation  was  found  to  proceed  from  a  small  fissure  which 
could  be  detected  only  by  bending  the  mucous  membrane  sharply, 
the  little  defect  showing  as  the  weave  would  show  on  folding  a 
piece  of  velvet.  Eighty  of  the  231  cases  belong  to  this  group  of 
non-indurated  ulcers,  56  being  females  and  24  males.  One  in- 
teresting diagnostic  feature  was  first  pointed  out  by  Lund,  He 
noted  that  an  ulcer  could  sometimes  be  located  by  an  enlarged 
"sentinel"  gland  in  the  omentum,  tributary  to  the  lesion.  We 
have  noted  for  a  long  time  that  in  nearly  all  oi)en  ulcers  the 
tributary  lymphatic  glands  were  definitely  enlarged  to  the  size  of 
a  lima-bean,  from  1  cm.  to  1.5  cm.  in  diameter,  usually  in  the  gastro- 


272  WILLLVM   J.    MAYO 

colic  omentum,  in  this  respect  being  unlike  cancer,  which  affects 
the  glands  of  the  lesser  curvature  by  preference.  The  enlarge- 
ment is  soft  and  shows  simple  adenitis.  It  is  probable  that  this 
may  be  a  valuable  diagnostic  sign,  and  that  we  should  find  en- 
larged glands  in  all  cases  of  ulcer,  mucous  or  otherwise.  The 
value  of  the  sign  is  somewhat  lessened  because  we  have  seen  adeni- 
tis in  the  same  situation  in  cases  of  cholecystitis;  but  in  these  cases 
enlarged  glands  were  also  found  along  the  common  duct. 

The  question  of  non-indurated  ulcer  needs  further  elucidation. 
The  very  fact  that  the  condition  may  not  be  cleared  up  at  the 
operating  table  prevents  us  from  gaining  knowledge  by  the  ex- 
perience. We  know  that  the  majority  of  well-selected  subjects 
recover;  but  a  minority  give  less  favorable  results,  and  operating 
for  purely  medical  indications  leads  to  unscientific  and  at  times 
indiscriminate  resort  to  operation.  Especially  is  this  true  of 
that  vast  army  of  neurasthenics  with  gastric  symptoms  depend- 
ing on  a  neurosis — a  complaint  simulating  ulcer:  a  prolapsed, 
splashy  stomach,  a  too  ready  diagnosis  followed  by  an  ill-advised 
gastro-enterostomy.  The  fact  that  the  stomach  appears  to  be 
normal  is  explained  by  the  inability  always  to  locate  a  mu- 
cous ulcer.  This  is  not  a  fanciful  nor  overdrawn  picture. 
There  is  seldom  a  week  but  several  such  cases  present  themselves 
at  our  clinic  and  are  refused  operation.  Many  of  them  have 
already  had  their  movable  organs  fixed  (kidney  and  uterus),  and 
the  removable  ones  removed  (ovaries,  appendix,  etc.),  and  now  are 
anxious  to  secure  relief  by  a  further  resort  to  the  knife.  That 
such  cases  are  frequently  operated  on  cannot  be  questioned,  and 
that  they  will  tend  to  bring  surgery  of  the  stomach  into  disrepute 
is  equally  certain.  The  so-called  atonic  dilatations  are  not  often 
greatly  benefited  by  operation  unless  there  is  marked  and  persis- 
tent delay  of  food  in  the  stomach.  This  group  is  closely  allied  to 
the  neurasthenic  class,  and  the  individual  case  must  be  carefully 
considered,  with  a  prejudice  against  operation  unless  it  can  be 
clearly  shown  to  be  indicated.  Fortunately,  the  field  of  gastric 
surgery  is  too  large  for  a  few  of  these  unfortunate  instances  to 
affect  the  general  results,  but  I  would  urge  on  the  profession  the 


Fig.  2Q. — Stomach  and  jejunum  drawn  into  clamps  (or  suturing.     Small  forceps  still  marking  low 

point  of  stomach. 


Fig.  30. — Shows  relation  of  the  duodenum  to  the  stomach. 


CHKONK'    1:L(  Kit    OF    STOMACH    AND    UUODEXUM — SURGERY      273 

necessity  of  eliminating  the  neunithenic  from  the  field  unless  the 
signs  and  symptoms  of  ulcer  are  distinct.  Of  course,  the  nervous 
condition  is  no. valid  reason  for  refusing  to  relieve  actual  disease. 

There  are  some  problems  closely  related  with  the  non-indurated 
ulcer  which  are  but  little  understood,  and  one  of  the  most  impor- 
tant of  these  is  pyloric  spasm.  Numerous  observations  at  the  op- 
erating table  have  convinced  us  that  pyloric  spasm  is  not  due  to  a 
contraction  of  the  pyloric  sphincter  alone,  but  of  any  part  or  all  of 
this  end  of  the  stomach. 

There  is  undoubtedly,  also,  such  an  entity  as  chronic  contrac- 
tion of  the  pyloric  muscle  without  actual  demonstrable  lesion,  and 
to  such  a  degree  as  to  be  the  onh'  evident  cause  of  gastric  dilata- 
tion, stagnation  of  food,  and  chronic  distress.  A  serious  form  of 
interference  with  gastric  motility  has  been  noted  by  Ochsner, 
Finney,  ]Munro,  and  others,  in  which  there  is  chronic  dilatation  of 
the  stomach  and  duodenum  as  far  as  the  common  duct  of  the  liver, 
giving  rise  to  many  of  the  symptoms  of  obstruction.  Ochsner 
believes  this  condition  due  to  a  pathogenic  contraction  of  a 
normal  excess  of  muscle  in  the  second  portion  of  the  duodenum, 
which  he  has  demonstrated  anatomically.  Another  variety  of 
interference  with  gastric  motility  is  the  not  rare  condition  of  "  valve 
formation,"  in  which  a  high-lying  pylorus  is  held  taut  by  a  short 
gastrocolic  omentum.  I  have  met  with  a  small  number  of  such 
cases,  three  of  which  were  reported  before  the  surgical  section  of 
the  American  Medical  Association  at  Atlanta,  May,  1896. 

No  final  conclusions  can  be  drawn  from  our  personal  experi- 
ence, but  at  present  we  do  not  advise  operation  in  any  case  of 
acute  ulcer,  although  certain  complications,  such  as  perforation, 
hemorrhage,  and  grave  obstruction,  may  compel  its  speedy  perform- 
ance. We  do  not  advise  operation  in  chronic  ulcer  or  its  associated 
diseases  until  careful  and  prolonged  medical  treatment  has  failed 
to  cure  permanently,  and  we  strongly  advise  against  operation  in 
neurotic  individuals  with  prolapse  of  the  stomach.  We  advise 
operation  in  all  cases  of  stagnation  and  retention  of  food  depend- 
ing on  mechanical  causes,  such  as  pyloric  obstruction,  and  in  cases 
of  exhausting  hemorrhages.     We  ad\ise  and  practise  operation  in 

VOL.  I — 18 


274  willia:m  j.  ^l^yo 

that  considerable  group  of  chronic  cases  "«'ith  acute  exacerbations, 
in  whom  frequent  relapses  with  their  attendant  disabilities  prevent 
the  patient  from  the  enjoyment  of  good  health.  It  is  this  latter 
group  which  reminds  us  forcibly  of  the  early  days  of  appendicitis 
in  which  great  divergence  of  opinion  was  made  manifest,  from  the 
practitioner  who  rarely  saw  a  case,  to  the  equally  honest  man  who 
saw  them  frequently  but  always  cured  them  without  trouble. 
We  have  gone  through  the  same  controversy  as  to  the  surgical  treat- 
ment of  gall-stones  and  other  diseases. 

There  are  a  number  of  careful  observers  who  predict  that  the 
ultimate  field  of  gastric  surgery  will  be  small,  and  that  the  diagnosis 
of  surgical  conditions  cannot  often  be  made;  but  this  was  equally 
true  of  the  early  days  of  appendicitis,  of  gall-stone  disease,  and  of 
pyosalpinx.  I  think  no  unprejudiced  person  can  doubt  the  con- 
clusion that  gastric  and  duodenal  ulcers  and  associated  disorders 
are  more  frequent  maladies  than  we  have  been  led  to  believe,  and 
also  that  ulcer  or  some  of  its  numerous  compHcations  may  and 
often  does  produce  a  train  of  symptoms  which  medicine  is  power- 
less to  cure  permanently. 

What  percentage  of  gastric  and  duodenal  ulcers  may  be  ex- 
pected to  be  cured  bj"  medical  means?  Five  hundred  cases 
treated  medically  in  the  London  Hospital  in  the  five  years  from 
1897  to  1902  gave  a  percentage  of  18  for  the  death-rate,  and  42 
per  cent,  were  not  cured  at  the  time  of  discharge.  As  211  of  the 
500  had  been  cured  one  or  more  times  of  previous  attacks,  who  can 
predict  the  future  history  of  the  40  per  cent,  discharged  as  cured? 

Of  the  medically  treated  ulcers  in  the  Massachusetts  General 
Hospital,  Greenough  and  Joslin  showed  that  only  55  per  cent,  were 
discharged  as  cured,  and  56  per  cent,  supposed  to  be  cured  were 
dead  or  still  suffering  at  the  time  the  report  was  made,  five  years 
later.  Mumford  reports  only  4  per  cent,  of  gastric  dilatations 
resulting  from  ulcer  as  cured  medically  out  of  122  cases  in  the 
Massachusetts  General  Hospital.  Russell's  statistics,  derived  from 
a  large  number  of  out-patients,  show  that  42.6  per  cent,  of  patients 
with  gastric  ulcers  recovered;  but  as  it  was  the  first  attack  in  27.7 
per  cent,  and  might,  therefore,  be  called  acute,  this  gives  a  recovery 


CHRONIC  ULCER  OF  STO.MA(  11  AND  DUODENUM SUROKHY  "i  t O 

of  only  14.9  per  cent,  of  the  elironie  cases.  The  hahince  either 
died  or  continued  to  suffer  (Blake).  Munro  remarks,  "Is  it  not 
surprising  that  an  increasing  number  of  ulcer  subjects  are  sponta- 
neously seeking  surgical  relief?" 

It  is  wise  to  be  conservative  and  to  compel  each  new  departure 
to  bring  its  own  proof.  What  results  can  surgery  show  in  this 
field?  First,  it  has  denionslrated  the  clinical  frequency  of  ulcer 
of  the  stomach  and  duodenum,  not  a  new  thing,  because  it  has 
been  shown  for  years  in  the  autopsy  records;  second,  it  has  de- 
veloped a  symptomatology  which  enables  the  diagnosis  to  l)e 
made,  and  has  demonstrated  the  operative  curability  of  ulcer 
and  certain  associated  disorders.  Surgery  has  brought  back  to 
a  safe  ground  a  large  number  of  ulcer  victims  who,  after  repeated 
medical  cures,  had  taken  to  fakirs,  patent-medicine  venders. 
Christian  (?)  Science  (?),  or  were  making  the  best  of  their  condi- 
tion and  using  patent  foodless  foods  and  a  restricted  diet.  In 
doing  even  this  much,  surgery  has  been  open  to  sound  criticism, 
first  on  the  occasional  selection  of  an  unfortunate  case  for  opera- 
tion, and,  second,  on  the  occasional  unsatisfactory  results  of  opera- 
tive interference  both  as  to  mortality  and  to  permanence  of  cure. 
It  is  the  surgeon's  duty  to  overcome  this  prejudice  by  furnishing 
better  results. 

The  history  of  successful  gastric  surgery  is  not  more  than  five 
years  old,  and  the  best  of  it  not  of  over  two  years'  duration.  The 
medical  man  must  discard  the  older  statistics  as  to  technic  and 
mortality  which  have  become  merely  venerable  relics,  and  do  not 
at  all  represent  advanced  surgical  thought  on  the  subject.  It  is 
certainly  discouraging  to  turn  to  the  newer  works  on  medicine  and 
find  not  the  slightest  attemjit  made  to  show  the  advance  in  sur- 
gery, and  the  question  of  surgical  relief  being  arbitrarily  deter- 
mined by  the  achievements  of  tAvo  decads  ago. 

Surgery  is  essentially  mechanical,  and  must  benefit  the  patient 
in  a  mechanical  way  to  a  large  extent  (Fig.  26).  Most  surgical 
questions  connected  with  chronic  ulcer  arise  from  interference  with 
good  gastric  drainage,  either  by  actual  obstruction  or  by  muscular 
spasm,  so  that  the  food  and  secretions  are  subjected  to  delay  in 


276  WILLIAM    J.    MAYO 

that  part  of  the  stomach  lying  to  the  left  of  the  pyloric  muscular 
portion,  and  the  method  of  rehef  "^'hich  has  the  largest  field  of 
usefulness  consists  of  gastrojejunostomy  made  on  a  line  perpendic- 
ular with  the  cardiac  orifice  of  the  stomach  (Fig,  27).  This  "will 
usually  be  found  to  be  the  most  dependent  portion.  The  opening 
must  be  placed  on  the  posterior  wall,  at  the  very  bottom  of  the 
gastric  cavity,  and  should  extend  anteriorly  34  inch,  so  that  the 
jejunum  is  mortised  on  to  the  stomach  (Tig.  27).  The  line  of  the 
gastric  opening  should  be  that  of  ^Moynihan,  obHque  from  above 
doT\Ti  and  left  to  right  (Fig.  28).  The  jejunum  should  be  anasto- 
mosed within  three  inches  of  its  origin  (Fig.  28),  so  that  there  shall 
be  no  loop  (Fig.  29).  After  an  experience  of  somewhat  over  500 
gastro-enterostomies,  including  gastroduodenostomies  and  pyloro- 
plasties, we  have  come  to  Peterson's  conclusion  that  the  loop 
has  been  responsible  for  the  greater  part  of  the  evils  arising  after 
gastrojejunostomy,  such  as  bihary  regurgitant  vomiting  (vicious 
circle) .  The  intestine  should  be  secured  so  high  that  there  can  be 
little  loss  of  nutrient  absorbents.  The  straight  drop  of  the  bowel 
gives  protection  against  secondary  jejunal  ulcer  by  the  constant 
presence  of  the  alkahne  bihary  and  pancreatic  secretions,  and  also 
adds  to  the  security  against  future  comphcations.  There  is  no 
doubt  that  contraction  of  the  opening  is  less  liable  to  take  place  if 
there  is  no  loop  to  make  traction.  As  to  mortahty,  we  have  had 
less  than  3  per  cent,  mortahty  in  our  last  150  suture  operations, 
and  in  the  last  81  cases  of  benign  disease  there  has  been  but  1  death. 
These  results  are  no  better  than  those  of  Ochsner,  Murphy, 
Munro,  Deaver,  Robson,  Moynihan,  ]\likuhcz,  Kocher,  Hartmann, 
and  others. 

The  operation  here  advocated  has  given  us  better  results  than 
any  other  which  we  have  tried,  but  we  have  had  two  cases  of  chronic 
bile  regurgitation  occur,  e^adently  due  to  faulty  technic.  In 
both  patients  there  has  been  great  reUef  of  the  original  symptoms, 
and  in  neither  has  the  complication  as  yet  been  of  sufiicient  mo- 
ment to  require  a  second  operation. 

Next  to  gastrojejunostomy,  the  operation  of  gastroduodenos- 
tomy,  devised  by  Finney,  is  of  the  greatest  value.      It  is  espe- 


CHRONIC    ULCEK    OF    ST( J.MAC  II    AM)    IJUODEN  L M^SLUGKUY       277 

ciuUy  suited  to  narrow  strictures.  In  open  ulcer  it  does  not  drain 
the  stomach  to  the  i)roxinial  side  of  the  nuiscuhir  pyloric  region, 
and  the  food  must  still  pass  into  the  area  of  the  ulcer  to  reach  the 
outlet.  The  pyloroplasty  of  Heineke-Mikulicz  is  now  but  little 
practised,  and  the  method  of  closure  is  of  the  utmost  importance 
after  an  ulcer  is  excised.  As  a  matter  of  fact,  the  i)ylor<)plaslic 
principle  has  been  one  of  the  great  factors  in  modern  plastic  sur- 
gery. The  operation  of  Rodman,  consisting  of  a  complete  ex- 
cision of  the  entire  ulcer-bearing  muscular  pyloric  end  of  the  stom- 
ach, with  independent  gastrojejunostomy,  will  gain  ground  in  the 
future.  Graham  has  found  a  good  precancerous  history  of  ulcer 
or  associated  disorders  in  36  per  cent,  of  our  operated  cases  of 
cancer  of  the  stomach,  and  clear  evidence  of  cancer  development  on 
ulcer  in  30  per  cent,  of  the  last  40  pylorectomies  and  partial  gas- 
trectomies— certainly  an  argument  for  the  radical  operation. 
Excision  of  the  ulcer  may  be  of  value  in  a  small  group  of  cases  if 
there  be  no  obstruction  and  one  is  sure  that  only  one  ulcer  exists. 
Admitting  that  the  technic  and  mortality  of  gastric  surgery 
are  satisfactory,  have  the  patients  been  relieved?  Excluding 
some  cases  of  bad  selection,  I  can  conscientiously  say  that  we 
are  doing  no  surgery  today  which  gives  more  pleasing  results 
in  properly  selected  subjects  than  in  the  field  of  chronic  gastric 
and  duodenal  ulcer  and  associated  disorders.  The  disappoint- 
ments have  been  due  to  inability  to  secure  and  maintain  good 
gastric  drainage  through  imperfect  technic,  rather  than  failure  of  a 
properly  executed  operation  to  relieve.  While  gastrojejunostomy 
has  the  largest  field  of  usefulness,  we  must  not  look  upon  it  as  a 
"cure-all."  It  is  purely  a  drainage  operation.  If  the  stomach  is 
not  dilated  and  the  pylorus  be  unobstructed,  the  food  will  continue 
to  pass  out  the  normal  outlet  and  the  patient  will  not  be  benefited. 
For  this  reason  indurated  ulcers  with  definite  mechanical  lesions 
give  far  better  results  than  non-indurated  ulcers  in  which  obstruc- 
tions are  not  found,  and  it  is  this  latter  group  which  gives  a  con- 
siderable percentage  of  secondary  operations  and  complications. 
We  cannot  agree  with  the  opinion  which  has  recently  been  ad- 
vanced that  gastrojejunostomy  should  be  done  almost  regardless 


278  WILLIAM   J.    IVIAYO 

of  the  condition  present.  There  is  nothing  mysterious  about  this 
valuable  operation.  It  permits  retained  secretions  and  ingesta  to 
escape  readily.     If  motility  is  normal,  it  has  little  function. 

In  conclusion,  let  me  call  your  attention  to  the  vast  importance 
of  this  subject,  as  it  enables  us  to  differentiate  the  benign  from  the 
mahgnant  diseases  of  the  stomach.  Nearly  one-third  of  all  can- 
cers in  the  human  body  are  in  the  stomach.  In  70  patients  in 
whom  we  excised  a  large  part  of  the  stomach  4  "v\dth  cancer  lived 
more  than  three  years,  3  are  still  alive  and  without  return.  A 
number  of  patients  are  alive  over  two  years,  and  the  majority  live 
a  year.  The  average  mortality  was  12  per  cent.,  and  in  the  last 
40  cases  there  were  but  2  deaths— a  mortality  of  5  per  cent.* 

*  "Annals  of  Surgery,"  March,  1904. 


THE  SURGICAL  TREATMENT  OF  CANCER  OF 
THE  STOMACH.     REPORT  OF  100 
GASTRIC  RESECTIONS* 

WILLIAM    J.    MAYO 


In  the  history  of  medicine  we  have  no  recorded  example  of  a 
cancer  of  the  stomach  cured  by  medical  means.  Yet  for  some 
reason  or  reasons  such  cases  are  sent  to  the  medical  men,  are 
entered  in  the  medical  wards  of  hospitals,  and  subjected  to  treat- 
ment which  must  result  in  100  per  cent,  mortality.  This  is  so  true 
that,  while  cases  of  suspected  cancer  of  the  breast,  the  uterus, 
or  the  rectum  are  sent  at  once  to  the  surgical  side  from  the  out- 
patient department,  the  possible  victim  of  cancer  of  the  stomach, 
even  with  a  suspicion  amounting  almost  to  a  certainty,  is  still 
sent  to  the  medical  ward. 

Yet  of  all  the  diseases  of  the  stomach  cancer  is  the  one  which 
should  be  treated  surgically.  External  carcinomata  may  be  treated 
badly,  it  is  true,  by  plasters,  but  occasionally  with  success.  Super- 
ficial epithelial  growths  sometimes  disappear,  at  least  for  a  time, 
under  the  x-ray.  But  gastric  carcinoma  has  not  even  the  small 
chance  of  relief  afforded  by  these  uncertain  agents. 

Appendicitis  is  now  universally  conceded  to  be  a  surgical 
disease,  yet  some  cases  of  appendicitis  are  known  to  recover  spon- 
taneously and  to  remain  cured.  Extrauterine  pregnancy  may  re- 
sult in  a  pelvic  hematocele,  with  spontaneous  absorption;  but 
cancer  of  the  stomach  has  no  such  possibilities.  These  examples 
are  adduced  merely  to  show  the  inconsistency  of  looking  for  a 
medical  side  to  this  question.  It  is  worse  than  a  blunder:  it  is 
a  crime. 

*Reprintcd  from  "Jour.  Amer.  Med.  Assoc.,"  .\pril  7,  1906. 
279 


280  willia:m  j.  aliyo 

The  practitioner  of  medicine  is  not  to  blame  for  this  state  of 
affairs.  He  has  retained  these  cases  because  the  surgeon  has 
shown  Httle  or  no  disposition  to  reheve  him  of  the  responsibility. 
There  is  no  controversy,  and  no  one  is  more  anxious  to  turn  these 
unfortunate  victims  of  a  medically  incurable  disease  to  the  surgeon 
than  the  internist. 

Cancer  of  the  stomach  is  the  most  frequent  form  of  cancer 
found  in  the  human  body,  and  can  be  conservatively  estimated  at 
30  per  cent,  of  the  total.  WTiy  has  the  medical  profession  been  so 
slo"^  to  apply  surgical  methods  to  the  cure  of  this  common  malady? 
There  are  two  important  reasons :  First,  the  frightful  mortahty  of 
the  earher  operations,  which  discouraged  the  patient,  the  physician, 
and  the  surgeon;  second,  the  difficulties  and  uncertainties  of 
estabhshing  an  early  diagnosis. 

Review  of  Surgical  Treatment 
The  radical  removal  of  cancer  of  the  stomach  was  first  per- 
formed by  Pean  in  1879,  by  Rydygier  in  the  year  follo\s*ing,  and 
by  BiUroth  in  1881,  but  his  was  the  first  patient  who  recovered. 
Pean  and  Rydygier  did  not  reahze  the  importance  of  the  condition, 
and  it  remained  for  the  master  mind  of  Billroth  not  only  to  see  its 
possibilities,  but  to  establish  the  principles  of  operative  relief. 
These  remain  today  much  as  he  left  them,  the  changes  being  in 
technic  rather  than  in  new  discoveries.  Almost  equaling  Billroth 
in  the  importance  of  his  early  contributions  to  the  operative  treat- 
ment of  gastric  carcinoma  stands  the  name  of  Kocher,  and  in 
selected  cases  the  Kocher  operation  is  the  method  of  choice  not 
only  in  the  hands  of  its  distinguished  originator,  but  of  practical 
surgeons  the  world  over. 

The  death-rate  foUo^sang  these  early  operations  was  appalling. 
Billroth's  average  mortahty  at  the  time  of  his  death  was  over  60 
per  cent.  In  1896  Haberkant  collected  statistics  of  257  pylorec- 
tomies,  with  a  mortality  of  64.4  per  cent,  before  1887,  and  42.8 
per  cent,  after  that  time.  Goffe  showed  that  the  operative  mor- 
tahty among  the  English  and  American  surgeons  was  76  per  cent, 
before  1890  and  28.5  per  cent,  after  that  time.     Guinard  collated 


Fig.  31. — Showing  cancer  of  pyloric  end  of  stomach,  with  enlarged  glands  and  the  four  blood- 
vessels tied,  and  line  of  gastric  section:  A.  Left  gastro-epiploic  ligated;  B,  gastric  artery  ligated; 
C,  suixrior  pyloric  ligated;   D.  gastroduodenalis  ligated. 


'//J  Mayo 


Fig.  32. — Showing  duodenum  clamped  and  pyloric  end  of  stomach  separated,  ready  for  resection. 


SUItCIICAL    TUKAT.MKNT    (JF    CANCER    OF    HTO.MAfU  \iHl 

statistics  of  201  cases  between  18f)l  and  18f)H,  with  a  death-rate 
of  .'3,5. .'i  j)er  cent. 

The  lack  of  enthusiasm  of  all  the  parties  concerned  is  not  to  he 
wonderecl  at;  nevertheless,  there  has  been  steady  progress,  and 
since  1900  the  improvement  in  operative  technic  has  been  so  marked 
that  the  mortality  has  become  reduced  to  a  remarkable  degree. 

There  have  been  comparatively  few  workers  in  this  field,  and  the 
work  has  been  so  quietly  carried  on  that  the  bulk  of  the  i)rofession 
do  not  realize  the  enormous  progress  which  has  been  made.  To- 
day the  mortality  is  probably  not  above  10  per  cent,  in  the  operable 
cases  handled  by  men  of  experience,  and  in  suitable  cases  nearer  .3 
per  cent.  Operations  undertaken  with  the  patient  in  extreme 
exhaustion  from  starvation  and  hemorrhage  will  continue  to  show 
a  large  death-rate. 

But  these  disasters  should  no  more  militate  against  the  opera- 
tion in  suitable  cases  than  general  suppurative  peritonitis  should 
stand  in  the  way  of  early  operation  for  appendicitis;  they  should 
lead  us  rather  to  an  increased  effort  to  secure  the  patients  for  opera- 
tion during  the  curable  period. 

The  stomach  is  a  most  favorable  organ  from  an  operative  point 
of  view.  It  has  an  abundant  blood-supply  from  four  sources,  and 
the  certainty  of  early  wound  healing  makes  plastic  surgery  safe. 
The  immediate  ligation  of  these  four  vessels  makes  radical  opera- 
tion bloodless  and  devoid  of  shock,  exactly  as  in  cases  of  abdominal 
hysterectomy.  By  the  use  of  clamps  the  entire  area  can  be  cleanly 
excised  practically  without  opening  the  gastric  cavity  (Figs.  31 
and  32). 

The  gastric  envelops  are  thick,  with  but  a  loose  attachment 
between  the  combined  peritoneal  and  muscular  coats  and  the 
mucous  membrane,  so  that  a  firm  hold  of  the  outer  tunics  can  be 
secured  which  insures  reliable  union,  while  the  mucous  coat  can  be 
sutured  separately.  Running  sutures  are  particularly  effective 
and  save  much  time  (Fig.  33). 

The  entire  operation  of  pylorectomy  and  partial  gastrectomy 
can  be  performed  in  from  forty  minutes  to  an  hour  and  ten  minutes, 
including  opening  and  closing   the  abdomen;   at    this  time   only 


282  WILLIAM   J.   SL^TO 

will  an  anesthetic  be  urgently  demanded.  In  poor  subjects  the 
entire  visceral  part  of  the  operation  can  be  done  without  pain  and 
without  anesthesia.  The  preliminary  administration  of  morphin 
hypodermically  in  the  latter  class  of  cases  is  a  valuable  adjunct 
to  the  anesthesia. 

We  have  done  the  Billroth  No.  2,  that  is,  the  complete  closure 
(Fig.  35)  of  both  duodenal  and  gastric  stumps  and  independent 
gastrojejunostomy,  76  times,  and  the  Kocher  operation  15  times 
(Fig.  34),  and  the  Billroth  No.  1,  9  times.  Each  method  has  its  own 
field  of  usefulness  in  selected  cases.  For  the  average  case  the  Bill- 
roth No.  2  is  the  operation  of  choice. 

Granting  that  the  statistics  of  operative  procedure  are  now 
■ndthin  reasonable  hmitations,  is  the  rehef  afforded  sufficiently 
great  to  make  it  worth  while?  General  statistics  are  unsatisfac- 
tory, and  we  have,  therefore,  taken  only  those  of  Kocher,  Kronlein, 
Mikulicz,  and  our  own. 

In  1903  Kocher  reported  75  cases,  with  an  average  mortality 
of  29.3  per  cent.  Of  the  53  patients  who  recovered,  21  were  alive 
at  the  time  of  the  report  and  6  had  already  lived  more  than  three 
years,  1  alive  and  well  after  thirteen  years  and  1  after  eight  years. 
In  the  last  24  cases  there  were  but  4  deaths  (16  per  cent.),  and  2  of 
these,  Kocher  beheves,  could  be  fairly  excluded,  giving  a  mortality 
of  8  per  cent.  Matti,  of  Kocher's  clinic,  brings  the  Berne  statis- 
tics up  to  1904,  giving  a  total  of  100  gastric  resections.  There  was 
considerable  improvement  in  the  percentage  of  those  remaining 
cured  over  three  years,  and  it  was  further  shown  that  those  who 
died  of  recurrence  averaged  eighteen  months  of  comfortable  exis- 
tence, since  gastric  drainage  was  maintained  to  the  end. 

In  1902  Kronlein  reported  50  radical  operations,  with  14  deaths 
— 28  per  cent.  At  the  time  of  the  report  22  patients  were  living — 
4  three  years  and  upward,  7  more  than  two  years,  and  13  more  than 
one  year. 

In  1901  Mikuhcz  reported  100  gastric  resections,  with  37  deaths; 
58  of  the  patients  who  recovered  were  traced.  Seventeen  were 
alive  more  than  one  year,  10  more  than  two  years,  and  4  more  than 
two  and  one-half  years. 


VUtuMO. 


l^'K-  33- — Showing  closure  of  stomach,  and  the  throuRh-and-through  catgut  suture  two-thinls  com- 
pleted, and  outer  linen  continuous  Cushing  suture  just  started. 


ViJ  I  A/.(o 


Fig.  34. — Showing  restoration  of  gastro-intestinal  canal  after  Kocher  method.     Seromuscular  linen 
suture  in  behind,  and  through-and-through  catgut  just  beginning. 


SlK<il(  Al,    'lUKATMKNT    OF    CANCKU    Ul'    .STO.MA(  II  28ii 

We  (C.  II.  and  W.  J.  Mayo)  have  reseeted  Ihe  stomach 
100  times,  willi  11  deaths  \l  jxt  cent.  This  iiichidi's  every  case 
dyin^  iti  th(i  hospital  .')  alter  three  weeks  ami  '2  alter  more  than 
one  month.  In  the  hist  (53  cases,  be^dnnin^  with  Jannary  1,  1904, 
there  were  (5  deaths  (J). 5  i)er  cent.),  and  ^2.5  consecutive  case.s  with 
but  1  death. 

As  to  results,  17  of  the  100  operations  were  excluded  because 
|)erformed  for  indurated  ulcer,  in  which  ^Mstric  resection  seemed 
indicated  on  account  of  possible  existing  malignant  degeneration 
or  other  sufficient  reason.  Three  cases  of  cancer  were  also  ex- 
cluded because  the  diagnosis  was  not  proved  by  microscopic  ex- 
amination. This  gives  03  cases  of  gastric  cancer  wliich  have  been 
traced  in  which  radical  oi)erations  were  performed.  Nine  failed 
to  live  six  months;  14,  alive  now,  have  been  operated  on  too  re- 
cently to  be  of  value;  40  lived  from  six  months  to  a  year,  and  23 
are  alive  now;  25  from  one  to  two  years,  and  17  alive  now;  12 
from  two  to  three  years,  and  10  alive;  5  from  three  to  four  years, 
and  4  alive;   1  five  years,  and  is  alive  now. 

It  will  be  noted  that  5  of  our  cases  lived  over  three  years,  one 
dying  in  three  years  and  five  months  from  recurrence  in  the  liver. 
Since  but  18  who  survived  the  operation  were  operated  on  more 
than  three  years  ago,  we  have  27.7  per  cent,  living  three  years  and 
22.2  per  cent,  alive  and  well  over  three  years.  Taking  the  most 
gloomy  view  possible,  we  have  22  operated  on  more  than  three  years 
with  4  dying  as  a  result  of  the  operation,  5  living  over  three  years, 
or  22.7  per  cent.,  and  18.1  per  cent,  alive  and  well  over  three  years, 
a  showing  which  compares  favorably  with  the  operative  results 
for  cancer  in  other  parts  of  the  body. 

After  all,  the  ease  and  thoroughness  of  the  removal  of  the 
tributary  lymjihatics  tell  the  story  as  to  recurrence  of  cancer. 
Young  people  are  the  most  unfavorable  subjects  for  operation,  be- 
cause their  lymphatics  are  abundant;  old  people  less  so,  because, 
as  pointed  out  by  C.  H.  Mayo,  all  the  lymphatics  are  undergoing 
a  slow  but  sure  atrophy  during  adult  life,  so  that  the  aged  have 
actually,  as  well  as  relatively,  fewer  lym{)hatics. 

The  prospect  of  the  cure  of  cancer  of  the  cervix  uteri  is  inter- 


284  WILLIAM   J.    MAYO 

fered  with  by  the  proximity  of  the  ureters,  and  in  saving  them  we 
frequently  sacrifice  the  patient,  so  far  as  ultimate  cure  is  concerned, 
because  we  do  not  thoroughly  remove  the  tissues  at  this  vital  point. 
In  marked  contrast  to  this  is  the  arrangement  of  the  lymphatic 
absorbents  of  the  stomach,  which  have  been  so  beautifully  demon- 
strated by  Cuneo.  He  showed  that  normally  no  lymph-glands 
existed  to  the  left  of  the  middle  of  the  greater  curvature,  and  that 
the  lymphatic  circulation  of  this  area  was  from  left  to  right  (Fig. 
31).  Hartmann  seized  on  this  basic  principle  and  established  the 
line  of  gastric  section  on  the  greater  curvature  to  the  left  of  the 
lymph-nodes  unless  necessitated  by  the  growth  (Fig.  31).  Cuneo 
also  showed  that  the  lymphatics  of  the  lesser  curvature  lay  in  the 
wall  of  the  stomach  itself.  Mikulicz  at  once  comprehended  the 
necessity  of  routine  removal  of  all  the  lesser  curvature  to  the  gas- 
tric artery  (Fig.  31).  Kocher  had  already  shown  the  desirability 
of  the  removal  of  the  glands  lying  about  the  pylorus,  especially 
in  the  groove  with  the  gastroduodenal  artery  between  the  head 
of  the  pancreas  and  the  duodenum.  In  favorable  cases  the  entire 
lymph  absorbents  of  the  pyloric  end  of  the  stomach  can  be  extir- 
pated en  masse.  The  dome  of  the  stomach  is  disconnected  in  its 
lymphatic  arrangement  and  drains  into  the  splenic  glands  (Fig.  32)  • 

Diagnosis 

Exploratory  incision  is  the  only  way  in  which  an  early  diagnosis 
of  cancer  of  the  stomach  can  be  established. 

In  spite  of  the  remarkable  development  of  laboratory  methods, 
the  principal  diagnostic  means  are  clinical,  and  prolonged  attempts 
to  establish  a  laboratory  diagnosis  are  provocative  of  delay  and 
should  be  discouraged.  The  most  careful  and  painstaking  methods 
of  examination  including  these  means  should  be  insisted  upon,  but 
they  should  not  be  unduly  prolonged. 

A  suspicion  of  cancer  of  the  stomach  which  cannot  he  disproved 
by  known  methods  of  examination  within  a  short  space  of  time 
should  lead  the  conservative  practitioner  to  explain  his  suspicions 
to  the  patient  and  ask  for  surgical  consultation.  The  physician 
should  give  the  patient  the  benefit  of  the  doubt  under  such  cir- 


Fig.  ,55. — Gastr.i-inti>liii.il   caii.il    ri>l<iriil  \>\     ii'liiniulciU  |)n>iirior   Kaslrojujunostiimy.    Billroth 
No.  :.     Duixloniim  anil  iijiimim  dotted  in  as  they  lie  behind. 


SUHCK  At.  TKKAT.MKNT  OF  C'AN'f'ER  OF  STOMACH       28.5 

ciinislaiKc.s.  'J'lio  clinical  liislory,  with  tlic  clicinical  and  hiolofjicai 
exaininalion  of  tiie  stomach-contents,  can  only  lead  to  a  suspicion; 
and  we  nmsl,  act  upon  this  il"  we  arc  truly  conservatixc. 

(liven  a  patient  in  tiic  niiildle  jx-riod  of  life  who,  without  ap- 
parent cause,  begins  to  lose  flesh  and  strength,  is  unable  to  eat  as 
before,  and  whose  digestion  is  delayed,  we  have  a  right  to  suspect 
gastric  cancer.  If,  in  conjunction  with  this,  we  find  loss  of  motility 
and  a  delay  of  food  in  the  stomach,  with  evidences  of  blood  and 
reduction  of  hydrochloric  acid,  a  tentative  diagnosis  of  carcinoma 
is  justified. 

We  should  be  esi)ecially  suspicious  if  symi)toms  of  old  or  recent 
ulceration  are  obtained  in  the  history.  In  our  last  39  cases  56.4 
per  cent,  showed  direct  evidence  of  carcinoma  developing  on  ulcer. 
Graham  shows  a  clinical  history  of  ulcer  in  over  50  per  cent,  of  the 
cases  of  gastric  carcinoma  which  have  come  under  his  investiga- 
tion, although  years  may  have  elapsed  between  the  two  diseased 
processes.  It  is  possible  that  a  larger  number  of  patients  in  Avhom 
cancer  develops  secondary  to  ulcer  consult  the  surgeon  than  those 
without  this  history.  The  growing  frequency  of  operation  for  ulcer 
brings  patients  to  the  operating-table  for  the  relief  of  obstructions, 
deformities,  and  adhesions,  and  in  a  considerable  number  of  these 
patients  the  gastric  ulcer  has  undergone  cancerous  degeneration. 

Murphy  says:  "The  history  of  the  majority  of  patients  with 
cancer  of  the  stomach  will  show  precancerous  symptoms." 

This  question  cannot  be  settled  by  postmortem  evidence. 
For  example,  suppose  we  were  told  that  the  postmortem  examina- 
tion of  1000  women  who  died  of  cancer  of  the  cervix  uteri  did  not 
show  a  single  one  who  had  had  cervical  laceration.  Would  not  the 
query  at  once  arise :  If  the  cancer  was  so  extensive  that  the  patients 
died  of  the  disease,  how  would  it  be  possible  for  any  one  to  know 
by  such  postmortem  examination  whether  they  had  ever  had  lacera- 
tion or  not? 

Is  this  not  equally  true  of  ulcer?  Before  the  ]iatient  dies  all 
trace  of  the  ulcer  would  be  lost  in  the  gross  extent  of  the  disease. 

The  presence  of  a  tumor  is  not  necessarily  a  contraindication 
to  operation.     A  small  movable  growth  in  the  pyloric  end  of  the 


286  WILLIAM   J.    MAYO 

stomach  is  rather  a  favorable  indication,  since  the  early  obstruction 
attracts  the  attention  of  the  patient  by  producing  distressing  symp- 
toms which  might  not  have  come  on  at  all  if  the  tumor  were  in  the 
body  of  the  stomach. 

Fortunately,  80  per  cent,  of  all  gastric  carcinomata  are  in  the 
pyloric  end  and  along  the  lesser  curvature.  Seventy  per  cent,  are 
so  situated  as  to  interfere  mechanically  with  motility,  and  are, 
therefore,  operable,  while  10  per  cent,  are  situated  around  the 
cardia,  giving  evidences  of  esophageal  obstruction,  and  10  per  cent, 
are  in  other  parts  of  the  stomach. 

The  earlier  the  mechanical  symptoms  appear,  the  better  the 
prospect  of  early  diagnosis  and  cure. 

There  are  some  contraindications  without  exploration.  One 
of  the  chief  of  these  is  finding  typical  carcinomatous  glands  in  the 
supraclavicular  fossa,  particularly  on  the  left  side.  This  occasion- 
ally happens  where  the  diagnosis  may  be  plain,  but  the  question  of 
operation  is  less  plain.  Fixity  of  the  growth  and  the  presence  of 
ascitic  accumulations  are  also  contraindications.  Much  has  been 
written  about  the  value  of  blood  examination  in  cancer,  especially 
as  to  the  hemoglobin.  We  have  had  pylorectomy  cases  recover 
with  the  hemoglobin  as  low  as  30  per  cent.  Again,  some  of  the 
worst  cases  with  obstruction  may  give  a  high  percentage  of  hemo- 
globin due  to  concentration  of  blood  from  their  inability  to  absorb 
fluids. 

One  cannot  help  believing  that  more  persistent  attempts  to 
improve  the  early  diagnosis  of  cancer  would  have  followed  if 
better  operative  results  had  been  obtained.  This  excuse  no  longer 
exists  with  an  improvement  in  the  mortality  of  about  10  per  cent, 
and  25  per  cent,  of  the  operative  recoveries  living  more  than  three 
years.  The  time  has  come  for  energetic  action.  All  other  means 
have  failed,  and  exploratory  incision  of  the  suspected  case  is  the 
only  known  means  of  early  diagnosis.  This  should  not  discourage 
us,  but  should  rather  encourage  better  directed  efforts  toward 
securing:  less  formidable  means  of  ascertaining  the  truth. 


SURGICAL   TREATMENT   OF    CAXCEIi   OK   STOMACH  287 

Steps  of  tiik  Oi'KiiATio.v 

1.  Anesthesia. — We  prefer  ether  anesthesia,  giving  a  hypo- 
dermic injection  of  36  grain  of  morphin  tliirty  minutes  previous  to 
its  a(hninist ration.  During  the  major  i)art  of  the  operation  no 
anesthetic  is  required,  since  there  is  no  j)ain  experienced  during 
the  progress  of  the  visceral  work. 

2.  Exploration. — A  short  incision  is  made  in  the  midline,  half- 
way between  the  umbilicus  and  the  ensiform  cartilage.  Two 
fingers  are  introduced,  and  the  growth  is  explored  with  reference 
to  other  structures.  Next  the  extent  of  glandular  involvement  is 
ascertained.  If  the  case  seems  fairly  reasonable  for  operation,  the 
incision  is  rapidly  enlarged  and  the  growth  drawn  out  of  the  abdo- 
men. This  manoeuver  permits  careful  examination  of  the  lesser 
curvature,  especially  as  to  whether  the  infiltration  in  this  vicinity 
extends  beyond  the  possibility  of  removal.  The  transverse  meso- 
colon is  then  inspected,  as  it  is  often  infiltrated  from  behind.  The 
posterior  surface  of  the  stomach  and  its  relation  to  the  pancreas 
are  palpated  with  fingers  passed  through  a  rent  in  the  gastro- 
hepatic  omentum.  We  have  dissected  into  the  superficial  surface 
of  the  pancreas  a  number  of  times  without  that  fatality  to  which 
Haberkant  (76  per  cent.)  and  Mikulicz  (74  per  cent.)  have  called 
attention. 

3.  Mobilization  of  the  Lesser  Curvature  (Figs.  31  and  32). — The 
stomach  is  drawn  firmly  downward  and  to  the  right,  the  left  lobe 
of  the  liver  raised  by  the  fingers  of  an  assistant,  and  the  gastric 
artery  tied  with  catgut  on  a  needle  at  the  highest  possible  point 
well  beyond  the  lymphatic  nodes.  A  pair  of  clamps  are  caught  on 
the  opposite  side,  and  the  artery  and  that  portion  of  the  gastro- 
hepatic  ligament  which  has  been  ligated  with  it  are  cut.  With  a 
few  nicks  of  the  knife  the  pedicle  is  partly  detached  from  the 
stomach  and  allowed  to  retract.  This  permits  mobilization  of  the 
gastric  wall  and  obtains  a  clear  space  near  the  esophagus  for  the 
division  of  the  stomach.  The  superior  pyloric  artery  and  the  re- 
mainder of  the  gastrohepatic  ligament  are  now  doubly  tied  and  cut 
between,   leaving  the  glands  attached  to   the  duodemmi.     This 


288  WILLIAM   J.    MAYO 

mobilizes  the  entire  lesser  curvature  and  makes  the  remainder  of 
the  work  outside  of  the  body. 

4.  Separation  of  the  Pyloric  End  of  the  Stomach  {Figs.  31  and  32) . 
— The  hand  is  passed  into  the  lesser  cavity  of  the  peritoneum  be- 
hind the  stomach,  adhesions  are  carefully  divided,  and  bleeding 
points  ligated.  Hot  moist  gauze  pads  are  now  placed  in  this  space. 
Two  pairs  of  narrow  crushing  clamps  (Ferguson)  are  now  placed 
on  the  duodenum  well  below  the  disease  (as  a  rule,  an  inch  below 
the  pylorus),  and  the  duodenum  is  divided  between.  The  glands 
lying  in  the  omentum  immediately  below  the  pylorus  are  carefully 
dissected  upward,  so  as  to  remain  attached  to  the  pyloric  end  of 
the  stomach,  and  a  few  bleeding  points  caught  and  ligated.  The 
forceps  on  the  stomach  side  with  these  glands  is  now  lifted  sharply 
upward,  exposing  the  gastroduodenal  artery  in  the  groove  between 
the  head  of  the  pancreas  and  the  duodenum;  this  vessel  is  doubly 
tied  and  divided  between  ligatures.  The  glands  in  this  region  are 
dissected  upward  with  the  fat  and  hot  gauze  compresses  placed  in 
the  space. 

5.  Freeing  the  Greater  Curvature  {Figs.  31  and  32) . — The  gastro- 
colic omentum  is  tied  and  divided  in  sections  below  the  inferior 
coronary  vessels,  care  being  taken  to  avoid  the  middle  colic  artery; 
accidental  inclusion  of  this  vessel  has  caused  gangrene  of  the  trans- 
verse colon,  of  which  it  is  the  sole  blood-supply  in  15  per  cent,  of  the 
cases  (Kronlein).  Injury  to  the  middle  colic  has  necessitated  re- 
section of  the  transverse  colon  in  a  number  of  instances  (Kocher). 
The  lymph-nodes  lie  close  to  the  blood-vessels,  and  at  a  point  well 
beyond  these  structures  the  left  gastro-epiploic  vessel  is  caught  and 
tied.  Care  should  be  taken  not  to  destroy  its  branches  to  the 
stomach  beyond  the  point  of  ligation,  as  it  will  be  the  sole  blood- 
supply  for  the  contiguous  stomach- wall. 

6.  Removal  of  the  Diseased  Structures  {Figs.  31  and  32). — ^Light 
elastic  holding  clamps  are  now  placed  on  the  stomach  an  inch  or 
more  back  of  the  proposed  line  of  resection,  a  second  pair  grasping 
the  tumor  side  and  the  growth  with  the  glands  and  fat  removed 
en  masse.  As  it  is  cut  loose,  several  catch  forceps  should  be  appHed 
to  the  margins  of  the  cut  gastric  surface,  projecting  beyond  the 


srUCKAL    TUKAT.MKNT    OI-'    CANCKIt    OV    STOMAf'II  28!) 

clamp  to  prevent  relraelion.  This  elaiiii)  is  straight,  cpiite  elastic, 
and  covered  with  rubber  so  that  it  will  not  crush  or  injure  the  gas- 
tric wall.  We  have  found  those  of  Seudder  very  satisfactory'.  The 
cut  gastric  wall  is  now  lightly  gone  over  with  the  actual  cautery, 
I)articularly  at  the  upper  {)art,  at  which  point  we  are  most  liable 
to  fail  to  get  well  beyond  the  disease. 

7.  Suture  of  the  Gastric  Stump  (Fig.  33). — After  rearranging 
the  hot  moist  packs  to  furnish  ample  protection,  with  No.  2 
chromic  catgut  on  a  straight  needle,  beginning  at  the  greater  curva- 
ture, a  running  suture  is  placed  through  all  the  coats  after  the 
method  of  Charles  H.  Mayo.  The  needle  enters  on  the  peritoneum 
at  one  margin,  passes  through  to  the  mucous  coat  and  directly 
back  on  the  same  side  from  mucous  coat  to  peritoneum.  By  doing 
this  alternately,  first  on  one  side  and  then  on  the  other,  by  a  single 
suture  the  peritoneal  surfaces  are  rolled  into  contact,  the  parts 
being  firmly  brought  into  apposition  and  the  hemorrhage  checked. 
On  api)roaching  the  lesser  curvature  it  will  usually  be  found  that 
the  clamps  are  too  close  to  the  edges  of  the  wound  to  permit  of  this 
manoeuver,  and  it  may  be  necessary  to  unclasp  them  in  suturing  the 
last  inch.  As  this  situation  is  also  under  considerable  tension,  it 
is  well  to  place  one  or  two  mattress  sutures  of  linen  at  the  upper 
end,  completely  and  permanently  to  secure  it,  rolling  the  first 
catgut  suture  in  by  a  wide  grasp  of  the  gastric  wall  far  enough  back 
to  permit  union  without  tension.  Any  point  not  well  turned  or 
showing  a  tendency  to  ooze  is  secured  by  an  independent  mattress 
suture  of  linen.  Beginning  now  at  the  greater  curvature,  a  fine 
linen  continuous  Gushing  suture  turns  in  the  gastric  wall  without 
tension  over  the  first  row. 

8.  Restoration  of  the  Gastro-intestinal  Canal. — (a)  After  the 
Method  of  Kocher  (Fig.  o.J). — After  careful  cleansing,  the  stonuich 
is  drawn  toward  the  duodenum.  If  it  is  sufficiently  mobile,  the 
Kocher  operation  is  performed,  the  duodenum  being  loosened  up  for 
the  purpose.  The  posterior  wall  of  the  stonuich  near  the  greater 
curvature,  at  a  distance  of  1}  2  to  2  inches  from  the  gastric  suture 
line  and  j)aralIol  with  it,  is  suturetl  to  the  posterior  duodenal  wall 
just  l)el()w  the  original  clamp  on  it  by  a  running  suture  of  linen. 

VOL.  I— 19 


290  WILLIAM   J.    MAYO 

One-sixth  inch  in  front  of  this,  and  just  opposite  the  duodenal  clamp, 
an  incision  is  made  through  the  peritoneal  and  muscular  coats  of 
the  stomach  to,  but  not  through,  the  mucous  coat.  The  clamp  on 
the  duodenum  is  now  removed,  its  cavity  opened  up  and  sponged 
out.  The  posterior  cut  wall  is  firmly  sutured  with  chromic  catgut 
on  a  curved  needle  in  front  of  the  posterior  linen  suture  through  all 
the  coats  of  the  duodenum  and  stomach,  using  a  Connell  or  button- 
hole stitch  until  the  posterior  inner  row  is  completed  half-way 
around.  The  mucous  membrane  of  the  stomach,  which  has  been 
sutured  behind  without  opening,  is  now  cut  through  and  its  sutured 
lower  margin  inspected  for  hemorrhage  or  lack  of  apposition,  and 
one  or  two  interrupted  sutures  of  catgut  applied  if  necessary. 
The  through-and-through  catgut  suture  is  now  continued  around 
the  anterior  surface,  uniting  the  end  of  the  duodenum  to  the  stom- 
ach in  a  similar  manner  to  that  previously  described  in  closing  the 
stomach,  the  suture  passing  from  peritoneum  to  mucous  coat  and 
back  from  mucous  coat  to  peritoneum  on  the  same  side  alternately 
and  tied  to  the  original  end.  The  linen  suture  is  now  continued 
around  to  the  starting-point,  completing  the  second  row.  The 
entire  suture  line  is  inspected  front  and  back,  and  several  extra  mat- 
tress sutures  of  linen  used  to  reinforce  at  points  of  tension.  If  the 
stomach  has  a  tendency  to  drag  on  the  duodenum,  the  gastrocolic 
omentum  close  to  the  stomach  is  caught  and  anchored  to  the 
peritoneum  on  the  left  margin  of  the  wound.  The  stumps  of  the 
gastrocoHc  omentum  are  brought  together  with  a  couple  of  catgut 
sutures  and  the  entire  field  inspected  and  sponged.  The  deep 
gauze  compresses  are  now  removed.  If  these  have  been  carefully 
placed  and  renewed  at  intervals,  there  will  have  been  no  contami- 
nation or  exposure,  (b)  Closure  of  the  Duodenal  Stump  and  Inde- 
pendent Gastrojejunostomy,  Billroth  No.  2  {Fig.  35). — If  the  stomach 
cannot  be  approximated  to  the  duodenum,  the  duodenal  stump  is 
turned  in  by  a  circular  suture  after  ligation  in  the  groove  made  by 
the  forceps  and  a  posterior  gastrojejunostomy  is  performed  without 
a  loop,  that  is,  within  three  inches  of  the  origin  of  the  jejunum.  The 
opening  in  the  stomach,  however,  should  run  from  above  down, 
right  to  left,  so  that  the  proximal  end  of  the  jejunum  shall  lie  close 


SURGICAL   TREATMENT    OF   CANCER    OF   STOMACH  291 

to  the  siituro  lino,  the  distal  oiul  at  the  lowest  point  and  f)assing  to 
the  left.  After  eoniplelion  of  the  gastrojejunostomy  in  the  usual 
manner  the  jejunum  at  once  drops  down  into  the  left  iliac  fossa  in 
its  normal  position.  A  few  sutures  close  the  rent  in  the  transverse 
mesocolon  in  such  fashion  as  to  protect  the  suture  line.  If  the 
j)ationt  is  in  a  poor  condition,  an  anterior  or  i)osterior  Murjjhy 
button  operation  can  be  made  to  save  time.  The  button  must  be 
protected,  however,  by  at  least  four  mattress  sutures  of  linen  at 
intervals  to  prevent  separation. 

.9.  After-care. — After  resection  the  patient  should  be  placed  in 
bed,  the  head  and  shoulders  elevated  to  the  semisitting  posture,  and 
a  glass  female  douche  point  introduced  above  the  internal  sphincter, 
through  which  from  one  to  four  quarts  of  one-half  strength  normal 
saline  solution  is  allowed  slowly  to  enter  the  rectum  for  absorption 
from  a  gravity  bag,  thirty  minutes  to  three  hours  being  used  in  this 
process  (Murphy).  This  is  repeated  in  twelve  hours  with  a  lesser 
amount.  From  one-half  to  one  ounce  of  hot  water  is  allowed  by 
the  stomach  every  hour  after  sixteen  hours,  and  the  usual  experi- 
mentation of  liquid  foods  begun  after  twenty-four  to  forty-eight 
hours,  the  rectum  being  used  as  an  auxiliary  for  four  or  five  days. 

Palliative  Operations 

The  results  of  palliative  operations  for  cancer  of  the  stomach 
are  relatively  unsatisfactory.  The  statistics  of  gastro-enterostomy 
for  the  relief  of  obstructions  due  to  inoperable  malignant  disease 
show  as  high  or  a  higher  mortality  than  gastric  resection;  the 
comparison,  hoAvever,  cannot  be  directly  made,  as  gastro-enteros- 
tomy can  be  applied  in  cases  in  which  radical  incision  cannot  be 
performed. 

The  average  prolongation  of  life  after  gastro-enterostomies  is 
not  over  four  to  six  months,  and  the  fact  that  patients  live  beyond 
this  time  gives  rise  to  the  query:  Might  not  radical  operation  have 
given  a  cure?  In  143  cases  of  gastro-enterostomy  for  malignant 
disease  reported  by  Mikulicz  the  mortality  was  33  per  cent.;  the 
average  prolongation  of  life,  (5.4  months.  In  74  cases  reported  by 
Kronlein  the  death-rate  was  24.3  per  cent.,  and  the  average  jiro- 


S92  WILLLIM   J.    iLVYO 

longation  of  life  was  but  three  months.  In  140  of  our  cases  the 
death-rate  was  15  per  cent,  and  the  average  prolongation  of  hfe,  so 
far  as  known,  was  less  than  five  months. 

It  is  true  that  the  mortahty  in  recent  cases  is  very  much  less, 
perhaps  not  over  10  per  cent.,  but  leaving  the  ulcerating,  bleeding 
mass  in  the  stomach  to  its  own  devices  is  unsatisfactory.  The 
operation  merely  prolongs  a  chronic  invalidism  by  a  few  weary 
months  which  are  without  hope.  The  judge  who  says  to  the  pris- 
oner "I  sentence  you  to  death  after  five  months"  has  not  given 
the  prisoner  a  desirable  intervening  existence. 

For  cancerous  obstruction  of  the  cardiac  orifice  gastrostomy 
offers  the  only  means  at  our  command,  a  palHation  which  is  not 
frequently  demanded  by  the  patient  when  the  facts  are  placed 
plainly  before  him. 

In  our  series  there  were  18  gastrostomies  for  cancerous  cardiac 
obstruction,  with  3  deaths — 16.6  per  cent.;  average  duration  of 
life  is  about  the  same  as  after  gastro-enterostomy. 

Of  explorations  with  the  discovery  of  hopeless  gastric  carcinoma 
there  were  72,  with  1  death  in  the  hospital.  The  average  stay  of 
patients  explored  for  incurable  disease  is  less  than  five  days,  the 
deep  wounds  being  closed  with  catgut,  and  the  strong  aponeurotic 
structures  are  braced  with  buried  mattress  sutures  of  linen,  silk, 
or  silver. 

It  will  be  seen  that  of  the  total  313  cancers  of  the  stomach 
operated  up  to  February  1, 1906,  only  26  per  cent,  were  early  enough 
to  permit  of  radical  extirpation. 

In  conclusion,  let  me  urge  upon  the  profession  the  merits  of 
radical  operation  on  suitable  cases  of  gastric  cancer. 


THE  TECHNIC  OF  (^,ASTROJEJUNOSTOMY 

WILLIAM    J.    MAYO 


The  results  following  gastrojejunostomy  arc  as  good  as  can 
l)e  reasonably  exjjected,  and  depend  more  upon  the  condition  of  the 
patient  at  the  time  of  operation  than  uj)on  the  technical  difficulties 
of  the  operation  itself.  The  mortality  is  no  longer  the  question 
considered.  This  is  particularly  true  of  the  posterior  suture 
operation,  a  procedure  we  used  130  times  in  sixteen  months  with 
l)ut  1  death.  These  results  are  not  exceptional,  and  have  been  and 
are  being  duplicated  by  many  other  surgeons.  Neither  need  we 
consider  those  serious  cases  of  regurgitant  vomiting  of  biliary  and 
pancreatic  secretions  during  the  first  week  (vicious  circle),  since 
this  complication  has  practically  disappeared  with  the  evolvement 
of  better  methods. 

While  we  can  congratulate  ourselves  upon  the  immediate 
safety  of  the  operation,  we  are  not  yet  free  from  certain  embar- 
rassing complications  which  may  arise  some  days  or  weeks  later. 
The  most  common  subsec^uent  condition  is  the  chronic  regurgita- 
tion of  bile  which  comes  on  at  intervals  in  a  small  percentage  of 
patients.  The  symptoms  vary  from  a  temi)orary  burning  in  the 
stomach,  due  to  the  entrance  through  the  fistula  of  biliary  and 
pancreatic  secretion,  to  the  most  distressing  vomiting  of  great 
f[uantities  of  such  fluids.  Ochsner  has  pointed  out  that  this  com- 
plication develops  usually  within  ten  weeks  following  the  opera- 
tion. On  reoperation  the  condition  is  found  to  be  due  to  a  partial 
kinking  or  obstruction  from  twisting,  adhesions,  or  other  cause, 
just  as  the  acute  "vicious  circle"  was  due  to  early  and  more  com- 
plete obstructions. 

*  Reprinted  from  "Annals  of  Surgery,"  April.  l!)0(l. 


294  WILLIAM   J.    MAYO 

Since  January  1,  1905,  Charles  H.  Mayo  and  I  have  discarded 
all  "loop"  operations,  T\-ith  or  without  entero-anastomosis  or 
closure  of  the  pylorus,  the  anastomosis  being  made  as  close  to  the 
origin  of  the  jejunum  as  possible.  The  results  as  compared  with 
all  previous  methods  in  our  hands  have  been  infinitely  better  in 
every  respect.  The  few  "loop"  operations  that  have  been  per- 
formed during  this  time  have  been  made  to  meet  special  indica- 
tions. 

From  January  1  to  July  1,  1905,  there  were  56  of  these  "no- 
loop"  operations,  with  but  1  death,  which  occurred  in  a  patient 
practically  moribund  at  the  time  of  operation.  Two  patients, 
however,  developed  chronic  bile  regurgitation  of  a  serious  char- 
acter. These  two  patients  are  the  ones  referred  to  in  a  paper  on 
"Chronic  Ulcer  of  the  Stomach  and  First  Portion  of  the  Duode- 
num," read  before  the  American  Medical  i^ssociation,  July,  1905, 
and  published  in  the  "Journal  of  the  American  Medical  Associa- 
tion," October  19,  1905.  Each  patient  had  gained  in  flesh  and 
weight,  being  reHeved  of  former  symptoms,  but  in  each  occasional 
regurgitation  of  quantities  of  biliary  and  pancreatic  secretions  was 
a  source  of  great  discomfort  and  considerable  disability.  Reopera- 
tion in  both  cases  during  the  past  summer  showed  that  the  cause 
of  the  trouble  was  an  angulation  of  the  jejunum  at  its  gastric 
attachment. 

In  all  the  56  cases  referred  to  the  anastomosis 'of  the  jejumma 
to  the  stomach  was  made  in  the  line  of  peristalsis,  that  is,  the 
proximal  portion  of  the  jejunum  was  attached  to  the  posterior 
gastric  wall  to  the  left  and  above,  and  the  distal  end  of  the  jejunum 
to  the  right  and  lower  part  of  the  stomach.  In  this  partial  twist- 
ing lay  the  secret  of  the  comphcation  (Fig.  36) . 

The  question  at  once  arises:  Is  the  idea  of  continuity  of  peri- 
stalsis between  the  stomach  and  jejunum  a  matter  of  conjecture,  or 
has  it  some  practical  significance?  The  writer  has  gone  over  in  a 
large  number  of  hving  subjects  the  anatomy  of  this  region,  and  the 
anatomic  facts  can  be  briefly  stated  as  follows: 

For  convenience  we  will  take  the  origin  of  the  jejunum  as 
being  at  the  point  in  which  the  duodenum  passes  through  the 


•_uij^-i^  y 


Fig.  ,^6. — Showing  kink  in  jejunum  resulting  from  changing  normal  direction  ol  its  uppermost 
portion,  in  ''no-loop"  gastrojejunostomy  after  posterior  method.  X  and  X  mark  commeDCcment 
of  jejunum. 


W. -J.  ''>^'-i^ 


Fig.  37. — Showing  no  kink  in  jejunum  resulting  from  preserving  normal  direction  of  its  upper- 
most portion,  in  "no-loop"  gastrojejunostomy  after  posterior  method.  X  and  X  mark  commence- 
ment of  jejunum. 


THE   TECHMC    i)V   GASTKOJEJL'XOSTOMY  29.5 

transverse  mesocolon.  Tlie  distal  end  of  llie  duodenum  lies  liehind 
the  stomach  when  the  latter  is  moderately  distended,  and  ahcjut 
1^2  inches  to  the  left  of  the  midline,  and  13^9  to  2  incites  ai>o\e  the 
umbilicus.  Its  horseshoe  shai)e  has  the  concavity  directed  to  the 
left  and  upward,  and  the  exit  is  within  about  two  inches  as  high 
as  the  pylorus.  The  transverse  portion  of  the  duodenum  passes 
forward  over  the  prominent  vertebral  column  and  backward  to  the 
left  side  of  the  spine  to  the  opening'  in  the  transverse  mesocolon. 
The  terminal  inch  which  marks  the  duodenojejunal  juncture  is 
directed  upward  and  to  the  left,  the  mesentery  of  the  proximal 
jejunum  lying  behind,  and  the  free  surface  of  the  intestine  directed 
forward.  The  jejunum  from  its  origin  drops  at  once  into  the  left 
abdominal  fossa.  Not  only  does  it  pass  to  the  left,  but  it  gravi- 
tates backward  into  the  left  kidney  pouch  underneath  the  splenic 
flexure  of  the  colon,  so  that  at  a  point  four  inches  from  its  origin  it 
lies  on  a  plane  to  the  left  and  posterior.  This  can  be  shown  in  a 
\'ery  practical  way  by  drawing  the  transverse  colon  out  through  the 
abdominal  incision,  pulling  it  upward  and  to  the  right  until  the 
mesocolon  is  taut.  This  brings  the  beginning  of  the  jejunum  into 
view.  It  will  readily  be  seen  therefore  that  if  the  attachment  is 
made  to  the  stomach,  so  that  the  proximal  portion  of  the  gastro- 
jejunostomy is  to  the  left  and  above,  and  the  distal  portion  is 
directed  to  the  right  and  below,  we  have  introduced  two  serious 
displacements.  The  jejunum  no  longer  falls  in  the  normal  manner 
to  the  left  and  backward,  but  is  artificially  caused  to  pass  not  only 
to  the  right,  but  forward,  as  it  must  ride  the  vertebral  column  or 
the  structures  immediately  contiguous.* 

The  active  propulsion  of  the  stomach  lies  in  the  pyloric  end, 
in  that  part  bounded  above  by  the  horizontal  portion  of  the  lesser 
curvature.  The  five-sixths  lying  to  the  left  has  mainly  storage 
function,  and  its  muscular  action  is  less  forceful.  The  proper  site 
for  the  gastric  incision  is  to  the  left  of  this  point,  on  a  line  with  the 
longitudinal  part  of  the  lesser  curvature,  with  its  lower  end  at  the 
bottom  of  the  stomach,  under  the  cardiac  orifice. 

*  For  variations  in  the  origin  of  the  duodenojejunal  angle  see  Mumford,  Testut, 
and  Cunningham. 


296  WILLIAM   J.    MAYO 

The  writer  has  been  unable  to  see  that  it  made  any  difference 
in  the  results  of  a  "no-loop"  gastrojejunostomy  whether  the  peri- 
stalsis of  the  stomach  is  the  same  as  that  of  the  intestine  or  not,  as, 
with  the  exception  of  a  tendency  to  contraction,  there  have  been 
no  complications  introduced  that  have  been  other  than  intestinal 
in  origin. 

Since  the  first  of  July,  1905,  we  have  abandoned  reversing  the 
jejunum,  and  in  a  larger  number  of  cases  (65)  we  have  had  no 
trouble  and  no  deaths.  We  apply  the  jejunum  to  the  posterior 
wall  of  the  stomach  from  right  to  left,  exactly  as  the  intestine  lies 
under  normal  conditions.  The  distal  portion  of  the  jejunum 
passes  from  the  bottom  of  the  stomach  directly  back  into  the  left 
fossa,  as  occurs  normally  (Fig.  37). 

Two  drawings,  made  from  sketches  of  the  actual  operations 
in  our  clinic,  explain  the  mechanical  conditions  very  perfectly. 
It  is  hardly  necessary  to  say  that  the  idea  of  the  reversal  of  the 
peristalsis  is  not  original  with  us,  but  will  be  found  in  the  litera- 
ture on  this  subject  to  have  been  advocated  at  various  times.  As 
a  matter  of  fact,  in  this  operation  it  is  of  no  importance. 

With  any  "loop"  operation,  four  inches  or  more  in  length,  the 
objections  which  we  here  make  to  the  mechanics  are  not  so  appar- 
ent, but  mechanical  difficulties  of  some  kind  are  so  frequently  in- 
troduced as  to  render  gastrojejunostomy  with  entero-anastomosis 
the  method  of  choice  with  the  larger  number  of  operators. 

The  "no-loop"  operation  directed  to  the  left,  as  outlined  above, 
has  given  us  vastly  better  results  than  any  other  method  with 
which  we  have  become  acquainted. 

Steps  of  the  Operation. — For  benign  disease  the  abdomen  is 
opened  from  three-fourths  to  one  inch  to  the  right  of  the  median 
line,  splitting  the  fibers  of  the  rectus  muscle.  The  transverse  colon 
is  drawn  out  of  the  abdominal  incision,  and  by  a  steady  traction 
to  the  right  and  upward  the  mesocolon  is  brought  out  until  the 
jejunum  comes  into  view,  and  the  intestine  is  grasped  at  a  point 
three  or  four  inches  from  its  origin.  On  drawing  the  jejunum 
tight  the  fold  of  peritoneum  which  covers  the  ligament  of  Treitz 
(a  small  band  containing  muscle-fibers)  is  developed.     This  peri- 


THE    TPXIINH'    OF    CiASTUOJh:JUNOSTOMY  '2!)7 

toiioal  hand  lias  its  ori^Mi;  on  llic  transverse  mesocolon,  and  extendi 
down  on  to  the  l)e<,'innin^'  of  the  jejnnum,  acting  as  a  suspensory 
ligament;  it  will  he  i'oiind  to  lead  to  the  base  of  the  vascular  anh 
of  the  middle  colic  artery,  and  accurately  marks  the  place  when- 
the  transverse  mesocolon  is  torn  through  to  secure  the  posterior 
wall  of  the  stomach.  The  stomach  is  drawn  through  this  opening 
and  the  anastomosis  performed,  beginning  at  a  point  one  inch 
above  the  greater  curvature,  on  a  line  with  the  longitudinal  por- 
tion of  the  lesser  curvature,  and  ending  at  the  bottom  of  the  stom- 
ach, i2'  2  inches  to  the  left.  To  secure  a  proper  low  point  a  small 
opening  is  made  in  the  gastrocolic  omentum,  and  one-half  inch  of 
the  anterior  wall  j)ulled  through  behind.  Having  these  features  in 
view,  a  considerable  portion  of  the  posterior  wall  is  drawn  into  a 
pair  of  light  elastic  curved  holding  clamps.  (We  prefer  the  Doyen.) 
The  handles  lie  to  the  right  and  about  transverse  with  the 
axis  of  the  body.  Beginning  13-2  to  3^2  inches  from  its  origin,  the 
jejunum  is  drawn  into  a  similar  pair  of  clamps  with  handles  to 
the  right.  It  will  thus  be  seen  that  the  left  low  point  on  the  stom- 
ach lies  in  the  tip  of  the  clamps,  and  the  distal  point  of  the  jejunum 
lies  also  to  the  left.  By  placing  the  two  clamps  side  by  side,  the 
operation  is  completed  in  the  usual  manner  by  two-row  suturing, 
chromic  catgut  suture  being  used  for  the  inner  through-and- 
through  mucous  stitch,  as  silk  or  linen  may  hang  ulcerating  for 
months  before  passing  away.  In  applying  this  suture  on  the  pos- 
terior row  behind  we  use  the  Connell  or  buttonhole  suture.  On 
the  anterior  we  use  the  method  advised  by  Charles  H.  Mayo,  which 
consists  in  entering  the  needle  on  the  peritoneal  side  through  to 
the  mucous,  and  directly  backward  from  mucous  to  peritoneum 
on  the  same  side.  By  doing  this  alternately,  first  on  one  side  and 
then  on  the  other,  with  this  first  chromic  catgut  suture,  the  peri- 
toneal surfaces  are  rolled  into  contact,  the  parts  to  be  united  are 
held  firmly  in  apposition,  and  the  hemorrhage  checked.  The 
outer  row  consists  of  No.  1  celluloid  linen  (Pagenstecher),  which 
we  have  used  with  great  satisfaction  since  it  was  introduced  for 
this  purpose  by  Robson.  It  is  very  strong,  smooth,  and  has  no 
capillarity.     Flattening  the  intestine  (Cannon  and  Blake)  shouM 


298  WILLIAM   J.    MAYO 

be  avoided  by  grasping  the  intestinal  wall  close  to  the  margin  of 
the  incision  -^dth  the  suture,  so  as  to  turn  in  a  narrow  seam  from  the 
intestinal  side.  On  the  gastric  side,  on  the  contrary,  one  need  not 
hesitate  to  take  a  free  grasp  of  the  tissues.  The  rent  in  the  meso- 
colon is  fastened  to  the  suture  line  mth  three  or  four  mattress 
sutures  of  hnen.  This  should  grasp  the  peritoneal  coat  close  to 
the  margins  of  the  rent  in  such  manner  that,  when  tied,  all  the 
raw  surfaces  shall  be  turned  in  behind  the  stomach,  and  the  per- 
itoneum folded  smoothly  against  the  gastrojejunostomy  opening, 
so  there  shall  be  nothing  to  cause  adhesions  between  the  meso- 
colon and  the  jejunum  beyond  the  anastomosis. 

This  short  communication  is  to  supplement  the  paper  on 
"Gastro-enterostomy,"  read  before  the  American  Surgical  Asso- 
ciation, July,  1905,  and  pubhshed  in  the  "Annals  of  Surgery," 
Xovember,  1905,  in  which  article  credit  has  been  given  to  origi- 
nators and  promoters  of  useful  suggestions  in  perfecting  this 
operation. 


THE    SURGICAL    TREATMENT    OF    GASTRIC 
AND  DUODENAL  ULCER  AND  ITS 
RESULTS* 

WILLIAM   J.    MAYO 


The  contributions  to  the  literature  of  ulcer  of  the  stomach  and 
duodenum  liave  become  so  numerous  that  it  will  be  impossible  in 
a  paper  of  this  character  to  give  credit  for  the  many  valuable  ad- 
vances which  have  been  brought  out  by  individual  workers.  I 
wish,  however,  to  express  my  appreciation  of  the  work  they  have 
done. 

For  more  than  twenty  years  the  complications  of  gastric  and 
duodenal  ulcers  have  received  surgical  attention.  Operations  for 
benign  stenosis  of  the  pylorus  and  some  acute  secondary  mani- 
festations have  occasionally  been  performed,  but  not  until  within 
the  last  five  years  has  there  been  a  surgical  invasion  into  the  field 
of  unhealed  ulcers  with  a  view  to  giving  relief  from  pain,  under- 
feeding, and  chronic  disability,  which  so  frequently  accompany  the 
disease. 

Acute  ulcers  of  the  stomach  and  duodenum  properly  belong  to 
the  domain  of  internal  medicine,  and  surgery  has  to  do  only  with 
the  complications,  such  as  perforation,  hemorrhage,  and  obstruc- 
tion. 

The  surgical  treatment  of  acute  perforations  of  the  stomach  and 
duodenum  is  now  on  a  sound  footing,  the  results  depending  on 
speedy  diagnosis  and  prompt  operative  relief.  Patients  operated 
on  within  the  first  five  hours  after  perforation  usually  recover; 

*  Read  in  the  joint  session  of  the  Sections  on  Practice  of  Medicine  and  Surgery 
and  Anatomy  of  the  American  Medical  Association,  at  the  Fifty-seventh  Annual 
Session,  June,  ll)0(i.  Reprinted  from  "Jour.  Amer.  Med.  Assoc,"  September  ii, 
1900. 

299 


300  WILLIAM   J.    MAYO 

after  ten  hours  the  majority  of  them  die.  We  have  had  7  gastric 
with  2  deaths  and  9  duodenal  with  3  deaths. 

Suture  of  the  perforation  and  pelvic  drainage,  with  or  without 
irrigation,  the  patient  maintained  in  the  semisitting  posture  (exag- 
gerated Fowler's)  for  several  days,  gives  the  best  results.  Whether 
or  not  a  gastrojejunostomy  shall  be  done  at  the  same  time  is  a 
moot  question,  since  a  considerable  percentage  of  patients  will 
develop  stricture,  adhesion,  or  other  deformity  in  the  healing  proc- 
ess following  perforation.  If  the  perforation  lies  in  the  duodenum 
or  close  to  the  pylorus,  it  should  be  sutured  transversely  to  avoid 
interference  with  the  lumen  of  the  part  involved.  Generally 
speaking,  if  it  seems  probable  that  stricture  or  other  secondary  con- 
dition will  result  and  the  patient  is  in  good  condition,  gastrojejun- 
ostomy should  be  performed,  providing  it  can  be  done  without 
spreading  the  infection  which  is  already  present.  If  in  doubt,  a 
living  patient  is  better  than  a  completed  operation  at  a  greatly 
enhanced  risk. 

Hemorrhage  from  the  stomach  occurs  in  two  forms,  acute  and 
chronic.  Recurring  acute  hemorrhages  are  best  treated  by  open- 
ing up  the  stomach  or  duodenum,  locating  the  bleeding  point,  and 
suturing  the  part  firmly  with  catgut  on  a  curved  needle  from  the 
inner  (mucous)  side.  The  outer  surface  is  then  exposed  and  pro- 
tected over  this  area  by  a  few  mattress  musculoperitoneal  sutures 
of  linen  (modified  Andrews  method).  We  have  not  found  gastro- 
jejunostomy for  acute  hemorrhage  a  reliable  procedure.  Out  of  6 
patients,  we  have  had  1  bleed  to  death  within  two  weeks  after 
gastrojejunostomy  and  a  second  was  saved  by  opening  up  and  se- 
curing the  bleeding  vessel,  while  5  who  have  been  treated  by  pri- 
mary operation  on  the  bleeding  point,  with  or  without  excision  of 
the  ulcer,  recovered. 

Chronic  hemorrhages,  on  the  contrary,  can  be  cared  for  by 
gastrojejunostomy,  especially  if  the  ulcer  is  situated  in  the  duo- 
denum or  near  the  pylorus.  In  a  number  of  instances  we  have, 
however,  excised  the  ulcer  and  closed  the  defect  by  plastic  opera- 
tion, planned  in  such  way  as  not  to  interfere  with  drainage  by 


StI<(;i(AL   TREATMFA'T    OF    OASTHK      \\l)    Ul  DlH.NAI.    I   I,<  Kit       .'501 

.su}).sequent  contraction.     In  several  of  these  cases  the  procedure 

ainoiintod  to  gastric  resections  with  end-to-end  suture. 

Chronic  Ulcer 

Chronic  ulcer  of  the  stomach  and  duodenum  is  more  common 
in  men,  and  is  essentially  a  disease  of  adult  life.  It  entails  upon 
the  victim  years  of  invalidism,  and  in  fully  25  per  cent,  is  the  direct 
cause  of  death,  while  indirectly,  through  anemia,  it  causes  general 
infections,  tuberculous  or  otherwise,  and  thus  doubles  the  mor- 
tality. Surgical  interference  should  be  considered  when  the  failure 
of  medical  treatment  is  made  manifest  by  a  continuance  of  the 
symptoms  or  frequent  relapses. 

Our  experience  (W.  J.  and  C.  H.  Mayo)  covers  600  operated 
cases  up  to  May  1,  1906 — 136  stomach,  13o  duodenal,  and  28 
stomach  and  duodenum.  In  46  cases  classified  as  duodenal  the 
duodenum  was  primarily  involved,  the  stomach  being  involved 
only  at  the  pyloric  ring.  It  was  rare  that  a  gastric  ulcer  did  not 
stop  abruptly  at  the  pylorus. 

Gastric  ulcers  were  multiple  in  less  than  15  per  cent,  of  the 
indurated,  and  estimated  at  about  20  per  cent,  of  the  mucous, 
lesions.  The  most  conmion  form  is  the  saddle  ulcer  of  the  lesser 
curvature  above  the  pylorus,  extending  flap  like  down  the  anterior 
and  posterior  wall  (prepyloric). 

Duodenal  ulcers  involve  the  two  inches  immediately  below  the 
pylorus,  and  extend  up  to  within  at  least  three-fourth  inch  of  it. 
In  all  but  o  cases  the  bow'el  lesion  was  single. 

Of  the  163  duodenal  ulcers,  77  per  cent,  were  males  and  23 
per  cent,  females,  and  in  all  but  7  cases  the  site  of  the  ulceration 
was  indurated,  the  thin  intestinal  wall  enabling  ready  identifica- 
tion. In  the  stomach,  on  the  contrary,  the  thick  tissues  sometimes 
prevented  accurate  localization  of  a  mucous  lesion,  the  proportion 
being  70  per  cent,  indurated  and  30  per  cent,  non-indurated. 
Three  of  the  acute  hemorrhagic  cases  were  of  the  mucous  variety, 
while  all  but  one  of  the  acute  perforations  occurred  through  the 
scar  of  a  partially  healed  ulceration. 

The  predominance  of  the  indurated  over  the  non-indurated 


302  WILLIAM   J.    MAYO 

ulcer  is  even  greater  than  would  appear  from  these  percentages. 
During  the  past  year  more  experienced  surgical  examination  has 
shown  that  over  85  per  cent,  of  the  gastric  ulcers  coming  to  opera- 
tion have  been  indurated,  and  less  than  15  per  cent,  non-indurated. 
There  is  no  question  but  that  the  frequency  of  non-indurated 
mucous  lesions  in  the  stomach  and  duodenum  has  been  and  still 
is  greatly  exaggerated.  The  very  large  majority  involve  all  the 
gastric  coats  and  are  capable  of  demonstration  at  the  operating- 
table.  Gastric  ulcers  were  found  with  nearly  the  same  frequency 
in  males  and  females.  In  this  connection  I  would  again  call 
attention  to  the  fact  that  ulcer  of  the  duodenum  is  nearly  as  com- 
mon as  ulcer  in  the  whole  of  the  stomach,  and  as  more  than  three- 
fourths  are  in  males,  the  increased  frequency  of  occurrence  of 
gastric  and  duodenal  ulcer  in  the  male  sex  is  accounted  for.  In 
our  earlier  work  duodenal  ulcers  in  the  vicinity  of  the  pylorus  were 
classed  as  pyloric  and  added  to  the  gastric  group.  In  the  past  two 
years  we  have  learned  to  differentiate  more  accurately,  and  in  the 
last  100  gastric  and  duodenal  ulcers  operated  on  47  were  duodenal, 
44  gastric,  and  9  had  an  independent  ulcer  of  each  organ;  62  were 
males  and  38  females;  87  out  of  the  100  were  of  the  indurated 
variety. 

That  a  very  large  proportion  of  chronic  ulcers  are  medically 
incurable  is  recognized  by  the  majority  of  unprejudiced  investiga- 
tors. It  now  remains  to  be  shown  whether  operative  treatment  is 
justified  by  its  results. 

Gastrojejunostomy 
Gastrojejunostomy  is  the  operation  which  has  justly  earned  the 
most  prominence  in  the  treatment  of  gastric  and  duodenal  ulcers. 
It  is  based  on  the  common-sense  principle  of  giving  rest  to  the 
diseased  part  by  diverting  the  food  and  gastric  secretions  to  a  new 
outlet,  which  should  be  on  the  storage  side  of  tjie  stomach,  at  its 
lowest  point  under  the  cardiac  orifice.  The  method  of  choice  is 
the  one  without  a  loop,  made  on  the  posterior  surface  through  an 
opening  in  the  transverse  mesocolon.  The  distal  end  of  the  je- 
junum is  attached  to  the  lowest  point  and  to  the  left,  the  proximal 


V/.I/vlAYO. 


Fig.  38. — Dotted  lines  show  posterior  "no-loop"  gastrojejunostomy 


WJJvlAYO. 


/r 


y^^  ^-A- 


_«^c 


Fig.  39. — Resection  of  hour-glass  stomach,  with  fields  in  gastrohepatic  and  gastrocolic  omenta  ligated. 
Dotted  lines  show  site  of  proposed  resection. 


SURGICAL  TREATMENT   OF   GASTRIC    AND    DUODENAL   ULCER      303 

part  to  the  rij^ht,  three-fourth  inch  above  the  greater  cur\'ature, 
givin<,'  jui  oi)eniii<,'  somewhat  oblique  from  above  down,  ri^'lit  to 
left,  not  less  than  two  inches  in  length  (Fig.  38).  The  torn  edges  of 
the  transverse  mesocolon  are  attached  to  the  suture  line  by  three 
mattress  sutures  in  such  manner  as  to  leave  a  perfectly  smooth 
j)eritoneal  border,  the  ragged  and  fatty  margins  being  tucked  up 
underneath  so  as  not  to  cause  adhesions.  It  is  imjjortant  that  the 
distal  end  of  the  jejunum  be  attached  as  it  lies  naturally,  that  it 
may  at  once  drop  to  the  left  and  posteriorly  in  its  normal  anatomic 
position. 

The  operation  thus  briefly  outlined  has  a  nominal  mortality. 
We  had  but  1  death  in  135  "no-loop"  operations.  The  anterior 
method,  preferably  with  a  Murphy  button  or  McGraw  ligature,  is 
occasionally  demanded  by  reason  of  posterior  adhesions  or  ab- 
normalities in  the  mesocolon  or  duodenojejunal  juncture;  but  as 
it  sacrifices  18  to  20  inches  of  the  most  important  part  of  the  upper 
jejunum,  it  cannot  be  considered  a  close  rival  to  the  posterior 
operation.  For  the  past  year  and  a  half  we  have  abandoned 
all  "loop"  operations  unless  forced  to  them,  and  in  no  case  do 
we  practise  entero-anastomosis  as  a  primary  procedure.  Of  the 
total  600  gastric  and  duodenal  ulcers,  383  (64  per  cent.)  were 
subjected  to  gastrojejunostomy. 

The  question  arises:  What  results  can  be  expected  from  gastro- 
jejunostomy? In  the  early  stages  of  any  subject  certain  proce- 
dures gain  a  reputation  which  later  experience  does  not  always  bear 
out.  While  gastrojejunostomy  is  by  all  odds  the  most  useful 
means  of  relief,  it  is  not  a  cure-all.  It  is  purely  a  drainage  opera- 
tion, and  as  in  a  large  majority  of  cases  the  ulcers  are  situated  in 
the  grinding  pyloric  end  of  the  stomach  or  upper  duodenum,  the 
alleviation  aflForded  is  certain  and  speedy.  But  if  the  lesion  does 
not  involve  permanent  interference  with  natural  drainage,  the 
food  will  eventually  pass  out  the  normal  opening  rather  than  the 
gastrojejunostomy,  and  a  certain  amount  of  shrinking  of  the 
anastomotic  stoma  or  angulation  may  follow. 

The  dangers  from  this  source  are  reduced  to  a  minimum  with  a 
"no-loop"    operation.     The  more  serious    the   interference   with 


301  WILLIAM    J.    ^L\YO 

the  normal  motility,  the  greater  the  relief  afforded  by  gastrojejun- 
ostomy, so  that  for  indurated  ulcer  it  is  the  method  "par  excel- 
lence." On  the  contrary,  in  mucous  lesions,  "^here  the  interfer- 
ence with  gastric  drainage  is  intermittent  and  due  to  muscular 
spasm,  the  results  are  less  certain. 

Gastroduodexostomy 
The  only  operation  on  the  stomach  of  any  consequence  which 
involves  a  new  principle  in  surgery  since  the  time  of  Billroth  is 
that  of  Finney.  It  leaves  the  opening  at  the  natural  situation, 
and  the  enlargement  is  doTNTiward  along  the  greater  curvature 
away  from  the  ulcer  area.  Gastroduodenostomy  is  especially 
applicable  to  those  mucous  lesions  which  interfere  with  drainage 
through  spasm.  It  supplements  gastrojejunostomy  admirably, 
as  its  scope  includes  those  cases  in  which  the  latter  method  has 
been  less  certain  of  cure,  and  it  has  superseded  pyloroplasty.  We 
have  had  72  cases  with  4  deaths,  and  the  very  large  majority  of 
those  who  recovered  have  remained  well. 

Excision  of  the  Ulcer 

Theoretically,  excision  of  the  ulcer  is  the  logical  procedure,  but 
it  must  be  shown  by  careful  examination  that  the  ulcer  excised  is 
the  only  one  present. 

The  saddle  ulcer  of  the  lesser  curvature,  if  it  does  not  interfere 
with  drainage,  should  be  excised  if  practicable  because,  as  has  been 
pointed  out,  if  the  stomach  is  not  dilated  and  the  pylorus  is  open, 
muscular  action  -^dll  continue  to  force  the  food  along  the  normal 
channel  rather  than  out  of  the  artificial  stoma.  Therefore,  a 
direct  attack  on  the  diseased  area  under  such  circumstances,  es- 
pecially when  the  margins  of  the  ulceration  are  hard  and  calloused, 
would  seem  to  be  sound  practice.  We  have  excised  ulcers  1-t 
times — 6  times  of  the  lesser  curvature  and  8  times  in  connection 
with  pyloroplasty  and  gastroduodenostomy,  with  no  deaths. 


W./Mayo. 


Fit;.  40. — Rescct'on  of  hour-slass  stomach,  inner  row  of  sutures  nearly  completed  (catgut),  outer  row 
completed  on  posterior  surface  and  beginning  on  upper  anterior  surface  (linen). 


surgical  treatment  of  gastric  and  duodenal  ulcer    305 

Rodman's  Operation 
Some  four  years  ago  it  was  suggested  by  William  Rodman  that 
since,  in  the  large  majority  of  instances,  ulcer  of  the  stomach  was 
in  the  pyloric  portion,  it  would  be  wise  to  resect  as  one  would  for 
cancer,  closing  both  duodenal  and  stomach  ends  completely  and 
reestablishing  the  gastro-intestinal  canal  by  an  independent  gas- 
trojejunostomy. We  have  performed  this  operation  nine  times 
with  great  satisfaction.  All  the  cases  recovered  and  have  re- 
mained well.  This  procedure  is  chiefly  indicated  in  indurated 
lesions  in  the  vicinity  of  the  pylorus. 

Resection  of  the  STOiL\CH 

The  treatment  of  hour-glass  stomach  by  some  form  of  plastic 
gastrogastrostomy  has  been  a  popular  operation,  but  in  the  ma- 
jority of  instances  the  ultimate  results  are  unsatisfactory',  as  it 
leaves  a  large  amount  of  scar  tissue,  and  if  it  happens  that  the  py- 
lorus is  involved  to  any  extent,  adequate  drainage  is  difEciJt  to 
secure. 

Gastrojejunostomy  on  the  proximal  pouch  does  not  prevent  a 
certain  amount  of  food  passing  into  the  distal  loculus,  where  it 
stagnates  on  account  of  loss  of  motility.  Multiple  gastrojejunos- 
tomies, one  for  each  loculus,  with  entero-anastomosis  beyond,  is  an 
unnecessarily  complicated  procedure,  especially  if  more  than  two 
lociili  are  present. 

In  l'-2  cases  without  a  death  we  have  resected  the  affected  por- 
tion of  the  stomach  in  the  following  manner  (Figs.  39  and  40) : 
The  gastrohepatic  and  gastrocolic  omenta  are  divided  and  sep- 
arated from  the  diseased  area;  a  straight  elastic  holding  clamp  is 
placed  on  the  proximal  side,  across  from  the  greater  to  the  lesser 
curvature,  about  one  inch  back  from  the  proposed  line  of  resection. 
On  the  distal  side  the  clamp  is  applied  obliquely  from  above  down, 
right  to  left,  to  increase  the  diameter  of  the  cut  surface,  saving 
from  the  greater  curvature.  In  this  way  we  have  been  able  to 
secure  on  the  distal  side  an  opening  two-thirds  the  size  of  the  proxi- 
mal one  for  suturing.     By  ha\'ing  one  inch  or  more  of  the  tissue 

VOL.  I — ^0 


303  WILLIAM   J.    MAYO 

projecting  beyond  the  clamps,  the  slack  on  the  large  or  proximal 
side  is  taken  up  with  each  suture,  the  bite  of  the  thread  taking  only 
two-thirds  of  the  amount  of  tissue  on  the  distal  portion,  a  difference 
of  diameter  of  one-third  being  disposed  of  in  this  manner  without 
seam  or  noticeable  pucker. 

If  the  ulcer  is  situated  close  to  the  pylorus,  an  end-to-end  union 
is  quite  easy  to  obtain.  In  two  cases  we  have  been  able  to  excise 
an  ulcer  of  the  duodenum  close  to  the  pylorus,  with  direct  union  of 
the  amputated  end  of  the  duodenum  to  the  stomach,  the  pylorus 
being  removed  in  both  instances. 

The  last  word  on  ulcer  of  the  stomach  has  not  been  written,  and 
it  is  evident  that  no  one  operation  will  be  applicable  to  all  varieties. 
At  the  present  time  it  would  seem  that  gastrojejunostomy  has  the 
largest  field  of  usefulness,  especially  in  those  cases  in  which  there  is 
permanent  interference  with  gastric  mobility  by  reason  of  ob-. 
structive  lesions  in  the  pyloric  end. 

For  those  cases  in  which  obstruction  is  due  to  spasm  or  other 
non-mechanical  cause  the  gastroduodenostomy  of  Finney  is  the 
operation  of  choice.  In  connection  with  this  latter  procedure  the 
excision  of  an  ulcer  of  either  the  stomach  or  duodenum  in  close 
proximity  to  the  pylorus  may  be  done  with  great  satisfaction. 

Gastric  ulcers  which  do  not  interfere  with  drainage  and  in 
which  there  is  no  loss  of  motility  should  be  directly  excised  if 
possible. 

Calloused  ulcers  of  large  size  and  thick  hard  margins,  whether 
hour-glass  or  not,  are  best  treated  by  some  form  of  gastric  resection, 
as  we  have  frequently  found  carcinomatous  degeneration  taking 
place  in  these  cases. 

The  large  majority  of  duodenal  ulcers  give  indications  for 
gastrojejunostomy.  There  are  few  exceptions  in  which  excision 
or  resection  will  give  better  results. 

It  can  be  shown  that  more  than  90  per  cent,  of  patients  suffer- 
ing from  gastric  and  duodenal  ulcer  who  have  been  subjected  to 
operation  have  been  cured.  Failures  are  more  often  due  to  tech- 
nical errors  resulting  in  bad  mechanics  than  to  the  inability  of  a 
properly,  executed  operation  to  cure  the  disease. 


SURGICAL   TREATMENT    OF    (lASTHlC    AM)    1)1  ODK.NAI.    I  I-(  KR       f5()7 

'1\)  one  wlio  cxpecls  to  practise  sur^eiy  of  the  stomacli  we  would 
stroiif^ly  recoiiiiiKMid  a  close  study  of  tlie  ^^astric  manifestations  of 
tlie  neurasthenic  stale.  Atonic  dilatations,  prolapse  of  the  sloni- 
ach,  and  tlie  various  <^astric  neuroses  jnay  sinuilate  ulcer  very 
closely,  and  u  careful  differentiation  is  absolutely  essential,  hccausc 
all  of  these  latter  conditions  are  unimproved  and  often  ac- 
centuated hy  operation,  bringing'  discredit  on  surgery  as  a  whole. 


THE    PRINCIPLES    UNDERLYING   THE    SUR- 
GERY OF  THE  STOMACH  AND 
ASSOCIATED  VISCERA* 

WILLIAM   J.    MAYO 


Clinical  surgery  in  the  past  as  applied  to  the  stomach  has 
lacked  an  accurate  physiologic  and  pathologic  basis.  Certain 
diseased  conditions  have  been  relieved  successfully,  but  often  the 
reason  for  the  results  have  not  been  satisfactorily  explained.  This 
is  especially  true  in  regard  to  function.  Our  knowledge  has  been 
founded  largely  upon  the  scientific  study  of  the  dead,  but  this  kind 
of  information  is  grievously  open  to  error,  inasmuch  as  secondary 
complications  and  terminal  infections  frequently  obscure  the  ini- 
tial lesion,  and  from  the  postmortem  evidence  we  are  not  always 
able  to  get  a  clear  mental  picture  of  the  disease  as  it  existed  during 
the  curable  period.  The  immediate  cause  of  death  may,  appar- 
ently, be  dissociated  from  the  primary  lesion,  which,  although 
completely  healed,  had  set  in  motion  the  fatal  pathologic  process. 
Medicine  is  greatly  indebted  to  postmortem  pathology  as  a  founda- 
tion, but  as  a  superstructure  it  has  a  less  exalted  position. 

Modern  surgery  has  dealt  with  the  practical  side  and  estab- 
lished a  "living  pathology."  It  has  cleared  up  those  three  great 
avenues  of  peritoneal  infection,  the  Fallopian  tube,  the  appendix, 
and  the  gall-bladder,  and  is  now  engaged  in  a  surgical  investigation 
of  the  diseases  of  the  stomach.  The  problems  to  be  elucidated, 
however,  are  very  different  from  those  just  mentioned,  as  infec- 
tions, primarily,  play  but  a  small  part  in  gastric  pathology.     The 

*  One  of  the  Mutter  lectures  delivered  before  the  College  of  Physicians,  Phila- 
delphia.    Reprinted  from  the  "Edinburgh  Med.  Jour.,"  January,  1907. 

■SOS 


SURGERY    OF    STOMACH    AM)    ASSOriATi:i)    VISfEIlA  300 

^'.ip  Ix'lwccii  I  he  kii<)\vl('(l;^e  obtiiiiied  from  i>().sttnortem  sliuiy  jind 
tlic  clinical  fin(liii<^s  inusl  ho  bridged  by  animal  experimentation. 

We  have  in  the  past  depended  too  much  upon  form  without 
inquiring  sufficiently  into  function.  At  present  there  is  an  extra- 
ordinary interest  in  physiologic  experimentation,  and  its  effect  upon 
surgery  has  l)een  most  beneficial.  The  work  of  Carrel,  Crile,  Gush- 
ing, and  especially  Cannon,  whose  investigations  in  this  field  have 
added  so  largely  to  our  knowledge,  are  conspicuous  examples  of 
the  trend  of  recent  progress. 

A  vast  amount  of  work  in  the  practical  and  comparative  anat- 
omy of  the  gastro-intestinal  tract  has  been  done  by  Cunningham, 
Huntington,  and  others,  and  in  the  experimental  physiology  of  the 
digestive  system  by  Pawlow,  Starling,  and  a  host  of  co-workers. 

It  is  with  the  view  of  bringing  together  and  correlating  some 
of  the  undigested  facts  in  embryology,  anatomy,  physiology,  and 
pathology,  which  have  a  bearing  on  sound  surgical  practice,  that 
this  pai)er  is  written. 

Embryology. — The  study  of  the  embryology  of  the  gastro-intes- 
tinal canal  is  most  interesting  and  instructive,  and  it  shows  how 
much  more  permanent  is  function  than  form.  The  primitive  in- 
testinal tube  is  composed  of  three  fundamental  parts,  the  foregut, 
midgut,  and  hindgut.  In  form  the  small  intestine  begins  at  the 
pylorus  and  the  large  intestine  at  the  ileocecal  valve,  but  func- 
tionally they  maintain  the  rudimentary  type,  the  small  intestine 
beginning  in  the  duodenum,  just  below  the  common  duct,  probably 
at  the  muscle  described  by  Ochsner,  which  he  has  shown  to  be 
found  near  the  juncture  of  the  second  and  third  portions  of  the 
duodenum  and  the  large  intestine  beginning  near  the  splenic 
flexure  of  the  colon  (Keith).  The  ancients,  in  calling  the  cecum  a 
"second  stomach,"  were  much  nearer  the  truth  than  we  thought. 

From  the  emliryologic  foregut  we  get  the  tongue,  the  back  wall 
of  the  pharynx,  the  esophagus,  the  stomach,  and  duodenum  to  its 
third  portion,  the  liver  and  pancreas  being  developed  from  the 
duodenal  end.  The  gall-bladder  and  common  duct  are  direct 
invaginations  of  duodenal  structures  (Cunningham).  It  will  be 
noted  that  all  these  organs  having  their  origin  in  the  foregut  have 


310  WILLIAM   J.    MAYO 

to  do  with  the  preparation  of  food  for  digestion,  but  are  not  them- 
selves capable  of  absorption.  The  stomach  and  duodenum  have 
some  selective  action  in  absorbing  certain  things,  such  as  stimu- 
lants, but  so  far  as  food  and  drink  are  concerned,  they  are  prac- 
tically unable  to  absorb.  In  operating  upon  the  upper  gastro- 
intestinal tract  soon  after  a  meal  I  have  frequently  noted  the  milky 
lines  made  by  the  full  lacteals  in  the  jejunum,  while  there  was  no 
such  appearance  above  this  point. 

The  duodenum,  with  its  wide  caliber  and  fixed  position  and 
with  its  delivery  point  nearly  as  high  as  its  pyloric  origin,  enables 
the  chyme  from  the  stomach  to  be  thoroughly  mixed  with  the 
pancreatic  and  biliary  juices,  absorption  taking  place  below 
Ochsner's  muscle.  The  jejunum  and  ileum  take  up  the  solid  por- 
tions of  the  food,  absorbing  at  least  90  per  cent,  of  the  proteids, 
but  by  no  means  do  they  make  way  with  all  the  fluids.  The  con- 
tents of  the  ileum  at  the  ileocecal  valve  are  still  in  the  liquid  state, 
though  the  ingesta  have  lost  the  bulk  of  their  nutritive  elements. 
The  cecum  absorbs  the  fluids  which  are  held  for  this  purpose 
between  the  ileocecal  apparatus  and  a  physiologic  muscular  con- 
tracture (the  cecocolic  sphincter)  near  the  hepatic  flexure  of  the 
colon.  In  this  intestinal  segment  the  contents  are  churned 
back  and  forth  until  the  fluids  have  been  reabsorbed  and  the  waste 
solids  driven  further  along  into  the  transverse  colon.  It  is  easily 
seen  that  the  midgut  retains  its  primitive  characteristics:  all  the 
absorption  takes  place  in  the  jejunum,  ileum,  cecum,  and  adjacent 
colon.  Man  prepares  his  food  with  the  organs  which  have  their 
origin  in  the  foregut,  and  absorbs  his  nutrition  from  the  derivatives 
of  the  midgut,  i.  e.,  he  eats  with  the  jejunum  and  ileum  and  drinks 
with  the  cecum.  The  posterior  "no-loop"  gastrojejunostomy 
does  not,  therefore,  deprive  the  patient  of  any  appreciable  amount 
of  absorbing  surface,  and  the  nutrition  is  in  every  respect  normal. 
The  cecal  function  explains  why  cholecystenterostomy  into  the 
hepatic  flexure  of  the  colon  has  proved  so  successful  an  alleviation 
in  complete  obstruction  of  the  common  bile-duct,  when  the  duo- 
denum for  any  reason  could  not  be  used  for  the  purpose.  When 
a  permanent  external  cholecystostomy  is  made,  the  patient  loses 


SURGERY   OF   STOMACH    AM)    ASSOCIATED    VISCERA  311 

with  the  bile  discharge  20  to  30  ounces  of  fluid  each  day,  thereby 
being  compelled  to  drink  a  larger  f|uanlify  of  liquid,  and  at  best 
shows  signs  of  dehydration,  whereas  when  the  bile  fluids  are  turned 
into  the  cecum,  they  are  quickly  reabsorbed.  The  effect  of  the 
bile  in  digestion,  especially  in  aiding  the  pancreatic  ferments,  is,  of 
course,  lost,  but  its  usefulness  upon  the  function  of  the  large  in- 
testine is  j)reser\'ed. 

The  value  of  water  in  the  human  economy  is  testified  to  by  the 
fact  that  it  is  redistilled  in  the  cecum  and  used  in  the  system  over 
and  over  again.  The  mechanical  effects  of  fluids  in  carrying  solids 
as  far  as  the  cecum  cannot  be  overestimated,  but  beyond  this 
situation  liquids  would  interfere  with  the  storage  function. 

The  primitive  hindgut  begins  near  the  splenic  flexure  of  the 
colon,  and  although  largely  a  matter  of  convenience,  this  portion 
of  the  intestine  has  a  very  considerable  nutritive  function.  The 
normal  action  of  the  colon  is  an  antiperistalsis,  except  during 
defecation.  In  his  most  admirable  address  on  Surgery  before  the 
British  Medical  Association  in  190,5  ^Ir.  Bond  shows  that  particles 
of  indigo-carmin,  placed  inside  the  anus,  are  carried  upward  by 
what  he  calls  "reverse  mucous  currents."  This  process  occurs 
close  to  the  intestinal  mucous  membrane,  and  takes  place  in  spite 
of  bowel  passages. 

Cannon,  in  his  experiments,  also  finds  that  antiperistalsis  is  the 
normal  movement  in  the  large  intestine.  By  selective  action 
valuable  food  elements,  and  especially  fluids,  are  carried  back  into 
the  cecum.  Great  advantage  has  been  taken  of  this  physio- 
logic fact  in  giving  saline  infusions  by  the  rectum.  Murphy 
has  shown  that  salines  introduced  very  slowly  into  the  rectum 
will  be  absorbed  with  great  rapidity,  largely  by  reverse  peristalsis 
to  the  cecum.  From  two  to  four  quarts,  which  otherwise  could 
not  be  introduced  into  the  body  except  by  hyperdermoclysis  or 
venous  transfusion,  can  be  taken  up  in  this  manner.  This  is 
especially  valuable  in  connection  with  gastric  surgery,  when  the 
stomach  is  not  available  and  fluids  are  essential. 

Comparative  ])hysiology  is  interesting  as  showing  that  in 
carnivorous  animals  digestion  is  practically  completed  in  the  small 


312  WILLIAM   J.    MAYO 

intestine,  while  in  the  herbivorous  the  colon  is  equally  important, 
on  account  of  the  liquid  nature  of  the  plant  and  grass  juices  upon 
which  they  depend  for  nourishment.  The  human  species  occupies 
an  intermediate  position. 

Anatomy. — The  dome  of  the  stomach  follows  the  curve  of  the 
diaphragm,  and  rises  above  the  esophageal  opening.  In  searching 
with  the  hand  in  the  stomach  for  the  cardiac  orifice  one  uncon- 
sciously tends  to  pass  above  the  actual  situation,  especially  as  on 
irritation  the  cardia  contracts,  leaving  the  mucous  membrane 
nearly  smooth.  A  little  dimple,  however,  can  be  found,  and  steady 
pressure  at  this  point  for  a  short  space  of  time  allows  the  finger  to 
pass  through  the  opening. 

The  lesser  curvature  has  a  somewhat  fixed  position;  in  the 
anesthetized  patient  about  two-thirds  of  its  extent  hangs  nearly 
longitudinal  with  the  long  axis  of  the  body,  while  the  lower  hori- 
zontal third  turns  sharply  to  the  right  and  somewhat  upward, 
varying  from  2  to  3}^  inches  in  length.  Distention  of  the  stomach 
comes  about  almost  entirely  through  alterations  in  the  relations  of 
the  greater  curvature. 

The  stomach  is  a  contractile  organ,  exercising  its  functions 
through  muscular  action,  gravity  playing  but  a  small  part  in  the 
onward  progress  of  food.  When  distended,  it  extends  downward 
and  to  the  right,  the  pylorus  being  carried  across  the  median  line 
and  upward  to  prevent  the  weight  of  the  food  resting  against  the 
pyloric  sphincter.  In  all  distended  organs  having  storage  function 
this  elevation  of  the  outlet  will  be  found  to  prevent  continuous 
exertion  of  muscular  force  for  retention  purposes,  as  shown  in  the 
urinary  and  gall-bladders. 

The  stomach  is  emptied  of  its  contents,  not  only  by  general 
contraction,  but  also  through  muscle-bands  which  extend  down- 
ward from  the  fundus,  grasping  the  greater  curvature  (Cannon). 
As  these  bands  contract  the  greater  curvature  is  shortened,  and 
the  pyloric  outlet  brought  more  nearly  to  the  bottom  of  the  cavity. 

In  a  general  way  it  can  be  said  that  all  the  stomach  lying  to  the 
left  of  the  longitudinal  part  of  the  lesser  curvature  has  storage 
function  (fundus),  about  four-fifths  of  the  whole  (Starling);    on 


SURGERY   OF   STOMACH    AND    A55SOCIATED   \XSCERA  313 

the  right,  having  the  horizontal  part  of  the  lesser  curvature  as  its 
superior  wall,  is  the  antrum,  the  grinding  fH)rtion  of  the  stomach. 
There  is  said  to  be  a  slight  thickening  of  the  circular  muscular  fibers 
at  the  entrance  to  this  cavity.  Starling  states  that  this  is  apparent 
rather  than  real,  and  that  the  antrum  is  a  physiologic  and  not  an 
anatomic  compartment.  By  contraction  of  these  circular  muscle- 
fibers  the  food-masses  are  held  powerfully  in  the  pyloric  end  during 
the  kneading  process,  some  prepared  chyme  escaping  through  the 
pylorus,  while  a  much  larger  amount  of  food  is  ejected  backward 
into  the  fundus,  which  steadily  compresses  the  whole.  In  pyloric 
obstruction  the  antrum  loses  its  identity  and  becomes  a  part  of  the 
distended  fundus,  as  in  the  cadaver,  accounting  for  the  perfect 
drainage  of  a  gastrojejunostomy;  whereas  if  the  same  operation 
is  done  and  the  pylorus  be  unobstructed,  the  artificial  stoma  fails 
to  drain,  and  is  often  productive  of  harm,  as  the  muscular  action 
of  the  stomach  propels  the  food  out  through  the  normal  outlet 
without  regard  to  the  gastro-enterostomy. 

The  terminal  three-fourth  inch  of  the  stomach  next  to  the 
pylorus  can  be  classed  with  the  pyloric  apparatus,  ha\-iiig  but 
comparatively  little  to  do  with  the  food-grinding,  and  acting  rather 
as  a  funnel  with  the  apex  at  the  pyloric  ring  (the  pyloric  canal  of 
Jonnesco).  The  pylorus,  under  the  muscular  contractions  of  the 
stomach,  projects  into  the  duodenum,  and,  from  the  duodenal 
side,  greatly  resembles  the  vaginal  portion  of  the  cer\'ix. 

The  importance  of  these  muscular  features  is  sho^ii  by  the 
fact  that  nearly  80  per  cent,  of  all  ulcers  of  the  stomach  are  situated 
in  this  grinding  pyloric  end,  the  most  common  variety  being  the 
saddle  ulcer  of  the  lesser  curvature,  extending  flap-like  down  the 
anterior  and  posterior  surfaces  (prepyloric).  The  ulcer  crater,  if 
one  be  present,  will  usually  be  found  upon  the  posterior  wall,  or 
there  will  be  two  ulcers  facing  each  other,  one  anterior  and  the 
other  posterior,  connected  superiorly  by  a  bridge  of  induration. 

The  pylorus  is  seldom  primarily  involved  in  idceration,  as  the 
pyloric  canal  is  normally  contracted  and  is  less  exposed  to  mechan- 
ical injury  or  the  presence  of  an  excess  of  acid  secretions.  The 
large  majority  of  so-called  pyloric  ulcers  are  in  reality  duodenal. 


314  WILLIAM   J.    MAYO 

The  latter  ulcer  extends  up  to  the  pylorus,  or  within  three-fourth 
inch  of  it,  in  96  per  cent,  of  all  the  cases;  error  in  accurate  localiza- 
tion has  led  to  mistaken  identification.  As  a  matter  of  fact,  we 
find  at  the  operating-table  that  no  less  than  40  per  cent,  of  all 
gastric  and  duodenal  ulcers  are  situated  in  the  duodenum. 

On  the  peritoneal  surface  of  the  gastric  side  of  the  pyloric  ring 
will  be  found  a  peculiar  arrangement  of  the  blood-vessels  which  is 
nearly  constant.  From  the  lower  side  a  thick  vein  passes  upward 
somewhat  more  than  half-way  upon  the  anterior  surface.  From 
the  upper  border  a  second  vein  reaches  downward  in  the  same  line, 
nearly,  if  not  quite,  meeting  the  first. 

Not  only  is  ulceration  most  frequent  in  the  antrum,  but  the 
topography  of  gastric  cancer  will  be  found  to  be  the  same  as  ulcer. 
In  54  per  cent,  of  134  resections  of  the  stomach  we  found  malignant 
disease  originating  in  the  submucous  tissue  at  the  margin  of  an 
ulcer.  Primary  cancer  of  the  duodenum,  however,  is  rare.  We 
have  seen  only  two  instances,  although  three  times  we  have  found 
carcinoma  developing  on  the  gastric  side  of  a  duodenal  ulcer  which 
had  involved  the  pylorus. 

The  pyloric  antrum  occupies  a  sheltered  position  under  the  left 
lobe  of  the  liver,  and  this  is  also  true  of  the  duodenum  above  the 
common  duct.  As  contrasted  with  the  remainder  of  the  stomach, 
acute  ulcer  perforations  into  the  free  peritoneal  cavity  are  rela- 
tively uncommon  in  the  antrum  on  account  of  the  ease  with  which 
adhesions  to  the  liver,  gastrohepatic  omentum,  and  suspensory 
ligament  and  gall-bladder  are  created,  and  these  tend  to  prevent  the 
gastric  contents  from  escaping.  The  cardiac  end  of  the  stomach 
has  no  such  protection,  and  although  this  region  has  but  10  per  cent, 
of  the  total  number  of  ulcers,  acute  unprotected  perforations  are 
more  frequent  here  than  in  the  entire  antrum.  Perforations  of 
duodenal  ulcers  are  more  common  than  gastric,  but  the  sheltered 
situation  of  the  duodenum  enables  ready  adhesive  protection,  while 
its  contents  are  nearly  sterile  and  relatively  small  in  amount. 

The  blood-vessels  supplying  the  stomach  are  all  from  the  celiac 
axis,  and  are  four  in  number:  the  gastric,  which  reaches  the  stom- 
ach on  the  lesser  curvature,  just  below  the  esophageal  opening;  the 


SURGKKY    OF    STOMArH    AND    AHSOCIATKIJ    VISCEKA  31;5 

superior  pyloric  branch  of  the  licjialic  artery  at  the  p\loriis;  the 
pistroduodciial,  which  gives  rise  to  the  right  gastro-cpiploic;  aiul 
the  left  gastro-epiploic,  from  the  splenic  artery. 

The  blood-vessels  of  the  lesser  curvature  lie  in  the  wall  of 
the  stomach;  those  of  the  greater  curvature  are  to  be  found  at 
a  considerable  distance  from  the  gastric  wall,  arterial  branches 
passing  upward  from  the  gastro-epiploics  upon  the  stomach, 
anterior  and  posterior,  in  a  sawback  manner.  When  the  stomach 
is  distended,  this  permits  the  greater  curvature  to  sag  downward 
toward  the  blood-vessels  without  compressing  them,  enabling  rapid 
changes  in  size  and  position. 

Tortuosity  of  the  uterine  arteries  makes  possible  the  great 
size  of  the  uterus  during  pregnancy,  because  it  comes  on  slowly; 
but  tortuosity  would  not  allow  the  rapid  changes  to  which  the 
vessels  of  the  greater  curvature  of  the  stomach  are  subjected.  By 
tying  the  four  blood-vessels,  gastrectomy  can  be  made  bloodless, 
just  as  hysterectomy  is  made  bloodless  in  the  modern  operation. 

The  lymphatic  arrangement  is  nearly  the  same  as  the  vascular, 
but  varies  in  one  important  particular.  On  the  greater  curvature 
no  lymph-nodes  are  to  be  found  to  the  left  of  its  middle,  and  the 
lymphatic  circulation  of  this  region  is  from  left  to  right  (Cuneo). 
Therefore,  in  radical  operations  for  cancer  it  is  possible  to  save 
a  great  deal  of  the  greater  curvature.  On  the  contrary,  in  the 
lesser  curvature  the  lymphatic  structures  lie  in  the  submucous 
tissues,  rendering  it  necessary,  in  every  case  of  carcinoma  of  the 
pyloric  end,  to  remove  all  the  lesser  curvature  as  high  as  the 
gastric  artery  (Mikulicz).  The  glands  about  the  pylorus  are  most 
numerous  on  the  inferior  surface,  although  several  are  found  just 
above  it  in  the  line  of  the  pyloric  artery.  The  relation  of  these 
glands  to  the  field  of  gastric  cancer  was  long  ago  dwelt  upon  by 
Kocher.  The  dome,  arising  above  and  to  the  left  of  the  cardiac 
orifice,  is  disconnected  from  the  remainder  of  the  stomach  in  its 
blood  and  lymphatic  supply  (Robson  and  Moynihan). 

In  a  general  way  the  lymphatics  of  the  stomach  greatly  re- 
semble the  other  hollow  viscera  of  the  bodv;   the  neck  of  organs 


316  WILLIAM   J.    MAYO 

is  the  region  of  the  lymphatics,  the  fundus  being  less  abundantly 
supplied. 

Physiology. — Thanks  to  the  investigations  of  a  large  number  of 
physiologists,  we  know  many  of  the  secrets  connected  with  the 
functions  of  the  stomach  and  duodenum.  One  important  fact 
developed  is  that  the  stomach  not  only  has  many  ferments,  but 
that  these  ferments  are  called  into  action  by  the  character  of  the 
ingesta,  and  they  can  be  increased  or  diminished  by  appropriate 
diet. 

Gastric  function  is  carried  on  to  a  considerable  extent  inde- 
pendent of  the  nerve-supply;  the  chyme,  when  ready  to  leave 
the  stomach,  has  attained  a  proper  acidity,  and  this  causes  con- 
traction of  the  gastric  muscles,  the  pylorus  automatically  opening 
to  permit  its  escape.  The  duodenum  also  has  control  over  the 
pylorus,  and  acidity  is  here  again  a  feature  influencing  the  pyloric 
closure.  According  to  Kelling,  the  chemistry  of  the  duodenal 
contents  is  the  most  important  agent  in  the  control  of  the  pylorus. 
The  mucous  membrane  of  the  antrum  produces  specific  substances 
called  hormones  (Starling),  which,  acting  with  nerve  impulses  such 
as  sight,  taste,  and  smell,  control  the  amount  of  food  ingested  and 
the  necessary  gastric  secretion. 

Not  only  is  much  of  this  process  the  result  of  chemistry,  but 
the  same  force,  through  the  vascular  system,  stimulates  the  gland- 
ular activity  of  the  liver  and  pancreas.  It  has  been  shown  that 
the  introduction  of  chyme  into  the  duodenum  causes  pancreatic 
secretion  by  means  of  a  product  of  the  intestinal  mucous  membrane 
called  "secretin,"  when  the  pancreas  has  no  connection  with  the 
body  except  its  blood-supply.  The  great  protective  agent  in  pre- 
venting self-digestion  in  the  stomach  is  mucus,  and  this  is  ap- 
parently true  of  the  entire  gastro-intestinal  canal. 

The  stomach  equalizes  the  temperature  of  the  ingesta,  macer- 
ates the  food-masses  in  a  weak  solution  of  hydrochloric  acid  and 
pepsin,  and  converts  the  contents  into  a  harmonious  whole,  the 
muscular  action  of  the  pyloric  antrum  being  the  active  agent  in 
the  latter  process.  The  cardiac  end  is  a  temporary  storehouse 
which  enables  its  possessor  rapidly  to  place  a  quantity  of  material 


SURGERY    OF    STOMACH    AND    ASSOCIATED    MSCERA  317 

where  it  can  be  drawn  upon  as  di^'cstion  proceeds.  To  a  large  ex- 
tent, then,  the  stomach  is  a  convenience,  and  obviates  the  necessity 
of  continuous  feeding,  just  as  the  urinary  bladder  and  the  large 
intestine  beyond  the  splenic  flexure  are  conveniences  to  prevent 
continuous  eliininalion. 

Excess  or  changed  secretions,  especially  acidity,  seem  to  lie 
behind  much  of  the  pathology  of  the  stomach,  accounting  largely 
for  ulcer  in  the  pyloric  antrum  and  duodenum  above  the  common 
duct,  with  its  alkaline  secretions.  Trauma  plays  an  important 
part  in  the  jiroduction  of  ulcer.  We  have  but  to  remember  the 
frequency  of  this  malady  in  the  grinding  pyloric  end  of  the  stomach, 
and  to  note  that  duodenal  ulcer  usually  originates  at  the  point 
which  received  the  impact  of  the  chyme  forcibly  ejected  from  the 
pylorus  to  appreciate  the  influence  of  local  injury  in  gastric  disease. 

It  has  been  thought  that  gastrojejunostomy  would  pass  the 
food  too  quickly  from  the  stomach  into  the  intestine.  This  belief, 
however,  has  been  proved  groundless,  as  the  stomach  does  not 
contract  in  such  a  manner  as  to  empty  its  contents  until  the 
proper  chemistry  has  been  reached  and  the  food  is  ground  in  the 
antrum  before  propulsion  is  begun. 

It  is  altogether  probable  that  modern  methods  of  food  prepara- 
tion have  greatly  changed  gastric  digestion,  and  that  a  considerable 
share  of  the  now  very  prevalent  diseases  of  the  stomach  are  due 
to  modern  dietary  changes  from  primitive  conditions,  just  as  the 
loss  of  necessity  for  the  grinding  action  of  the  teeth  has  resulted 
in  their  premature  decay. 

In  aboriginal  races  many  diseases  of  civilization,  such  as 
appendicitis,  gall-stones,  ulcer,  and  cancer,  seem  to  be  rare  (Senn). 

The  nerve-supply  of  the  stomach  is  of  two  kinds — the  vagus 
and  the  sympathetic.  During  fetal  rotation  the  stomach  turns 
upon  its  right  side,  which  thereby  becomes  the  posterior  wall,  and 
the  left  vagus  lies  anteriorly.  Terminal  filaments  of  the  vagi  join 
with  the  sympathetic  fibers  from  the  abdominal  ganglion,  and 
form  the  plexuses  of  Auerbach  and  Meissner,  which  lie  in  the 
gastro-intestinal  wall. 

The  control  of  the  cerebrospinal  nerves  over  the  stomach  is 


318  WILLIAM   J.    MAYO 

limited,  and  has  to  do  with  food  requirements,  but,  so  far  as 
actual  digestion  is  concerned,  the  sympathetic  is  the  controlling 
factor.  Beyond  the  stomach  the  cerebrospinal  nervous  system  is 
even  less  influential  until  the  sigmoid  and  rectum  are  reached, 
where  again  conscious  control  is  essential. 

The  sympathetic  nervous  system,  developed  from  mesoblastic 
tissue,  is  undoubtedly  the  primitive  one.  It  is  closely  allied  with 
the  control  that  is  inherent  in  the  gastro-intestinal  muscles,  and 
which  is  myogenic  in  origin,  and  of  the  same  nature  as  His'  heart- 
muscle  band,  which  regulates  the  heart-beat.  The  action  of  the 
gastro-intestinal  canal  is  regulated  largely  by  this  mysterious 
myogenic  force. 

The  sympathetic  nervous  system  has  retained  to  a  large  extent 
its  primitive  control  over  those  organs  which  have  to  do  with 
the  maintenance  of  the  body,  but  it  is  altogether  probable  that  it 
is  losing  its  prominence  on  account  of  the  overshadowing  develop- 
ment of  the  cerebrospinal  system,  and  just  as  other  vestiginal 
organs,  like  the  gall-bladder,  appendix,  and  wisdom  teeth,  seem  to 
develop  a  tendency  to  disease,  so  possibly  does  this  mysterious 
nerve  body.  It  is  within  the  realms  of  possibility  that  abdominal 
ptosis  and  many  forms  of  neurasthenia  are  characteristic  expres- 
sions of  evolutionary  instability  in  the  sympathetic  nervous  system. 

The  one  essential  difference  between  the  sympathetic  and 
cerebrospinal  nervous  system  is  that  the  sympathetic  is  not  seg- 
mented, and  is,  therefore,  unable  to  prevent  general  disturbances 
upon  irritation  of  any  of  its  component  parts.  This  is  especially 
interesting  in  connection  with  certain  diseases  of  the  stomach, 
which  are  exceedingly  misleading,  and  which  apparently  have  a 
common  origin,  such  as  pyloric  spasm,  atonic  dilatation,  prolapse 
of  the  stomach,  and  gastric  neuroses.  Now  that  surgery  of  the 
stomach  is  occupying  so  important  a  place,  it  is  vital  that  we  should 
eliminate  these  conditions  from  the  operating-room. 

We  have  had  an  opportunity,  in  a  considerable  number  of 
cases,  to  examine  the  stomach  during  that  contraction  of  the 
pyloric  canal  and  antrum  which  constitutes  "pyloric  spasm." 
This  muscular  contraction,  when  present,  causes  the  patient  to 


suk(;kky  of  stomach  and  asso(  iatkd  visckua  319 

oxporionco  a  sensation  wliicli  ho  speaks  of  as  "gas  pain."  It  can  he 
ohserved  in  operative  examination  under  local  anesthesia.  The 
peculiar  appearance  of  the  stomach  during  pyloric  spasm  may 
give  rise  to  the  belief  that  physical  disease  exists,  because  f)f  a 
rougliened,  puckered  appearance,  which  lasts  a  fraction  of  a 
minute,  and  then  changes  position  or  develops  a  rhythmic  contrac- 
tion, confined  to  the  antrum. 

In  tlie  most  extreme  degrees  we  have  found  it  in  connection  with 
stones  in  the  appendix,  impacted  gall-stones,  tuberculosis  of  the 
intestine,  and  chronic  intestinal  obstructions  of  various  kinds. 
Clinically,  it  would  appear  that  irritation  of  any  part  of  the  gastro- 
intestinal canal  and  allied  organs,  the  liver  and  pancreas,  may 
produce  j)yloric  spasm,  and  that  this  condition  may  overshadow 
the  local  disease.  The  greatest  care  is  necessary  in  differentiating 
these  cases  from  gastric  ulcer  and  other  inflammatory  infections. 

While  it  is  possible  that  pyloric  spasm  may  exist  as  the  result 
of  a  mucous  ulcer,  as  believed  by  von  Eiselsberg  and  Doyen,  such 
is  not  our  conviction,  although  it  will  mimic  gastric  ulcer  clinically, 
and  is  often  diagnosed  as  such.  "We  are  inclined  to  look  with 
a  great  deal  of  suspicion  upon  any  ulcer  of  the  stomach  which 
cannot  be  absolutely  demonstrated  not  only  to  the  operator,  but 
to  onlookers  as  well. 

Bacteriology. — The  contents  of  the  fasting  stomach  are  rela- 
tively sterile,  and  this  is  equally  true  at  the  height  of  digestion,  the 
chyme,  when  discharged  into  the  duodenum,  being  nearly  free 
from  pathogenic  organisms.  This  is  due  largely  to  the  acid  gastric 
secretion;  while  not  actively  germicidal,  the  general  influence  of 
all  the  secretions  of  the  stomach  are  against  germ  Ufe.  Cooking 
renders  a  large  amount  of  the  food  consumed  sterile,  but  many 
organisms  during  mastication  are  picked  up  from  the  mouth, 
which  teems  with  bacteria  of  all  kinds  (Harrington).  Cushing 
found  that  with  sterilized  food  the  discharge  from  a  jejunal  fistula 
was  free  of  microorganirsms  (providing  the  mouth  was  kept  in 
good  condition),  and  recommended,  in  addition  to  sterilizing  the 
food,  antiseptic  oral  washes  and  careful  cleansing  of  the  teeth 
previous   to   operations   upon   the   gastro-intestinal    tract.     The 


320  WILLIAM   J.    RIAYO 

vigorous  use  of  the  tooth-brush  to  those  who  are  not  accustomed 
to  it,  at  the  end  of  a  few  days  may  start  up  a  gingivitis,  and  tem- 
porarily increase  the  virulence  of  the  organisms.  Such  oral  anti- 
sepsis in  this  class  of  patients  should  begin  at  least  two  weeks  prior 
to  the  operation.  As  the  average  patient  cannot  be  kept  in  prep- 
aration such  a  length  of  time,  the  practical  importance  of  this  step 
in  the  individuals  just  referred  to  is  not  great.  A  moderate  number 
of  bacteria,  particularly  bacilli,  pass  with  the  food  into  the  duo- 
denum, and  members  of  the  colon  group  work  upward  from  below. 

Adami  and  Ford  have  shown  that  leukocytes  pass  out  upon 
the  free  mucous  surface  of  the  duodenum  and  upper  jejunum, 
picking  up  particles  of  fat  and  microorganisms  of  various  kinds, 
particularly  bacilli,  and  by  phagocytosis  destroy  them  in  the 
neighboring  lymphatics.  Some  bacteria,  however,  are  continu- 
ously carried  to  the  liver  and  there  annihilated,  the  pigments  of 
the  slaughtered  organisms  giving  rise  to  the  little  pigmented  areas 
sometimes  found  in  the  liver.  A  varying  number  of  bacteria, 
however,  are  passed  through  the  liver  and  excreted  with  the 
biliary  secretion.  The  bile,  therefore,  must  be  looked  upon  as 
always  infected,  and  it  is  probably  this  attenuated  infection  which 
gives  rise  to  gall-stone  disease  (Lartigau). 

The  relative  sterility  of  the  stomach  and  duodenum  and  the 
upper  jejunum  shows  why  gunshot  wounds  of  this  locality  have 
been  so  much  more  often  followed  by  recovery  when  operated 
upon  than  those  further  down  in  the  intestinal  tract. 

One  interesting  feature  in  this  connection  concerns  the  reason 
why  gall-stone  disease  is  so  much  more  frequent  in  women  than 
in  men.  In  1700  of  these  patients  upon  whom  we  have  operated 
three-fourths  have  been  women,  while  just  the  opposite  has  been 
true  of  duodenal  ulcer.  In  200  operated  cases  of  the  latter  disease 
73  per  cent,  were  males,  and  only  27  per  cent,  females.  Granting 
that  biliary  infection  is  equal  in  men  and  women,  is  this  sex  dis- 
proportion due  to  different  mechanical  conditions?  We  have  been 
investigating,  during  life,  a  considerable  number  of  patients,  with 
a  view  to  determining  whether  there  was  a  difference  in  the  arrange- 
ment of  the  duodenum  and  common  duct  which  favored  ascending 


SUHGKIiV    Ol'    ST().MA(H    AM)    ASSOCIATEO    \I.sri:KA  3-21 

^alI-l)Ia(l(lor  infection  in  women,  and  also  as  to  whetlier  the  nic- 
fliaiiics  in  men  were  uni'avoralile  for  [jermittinj;  the  alkahne  dis- 
charge from  the  common  duct  quickly  to  neutralize  that  excessive 
acidity  of  the  chyme  which  seems  to  lie  behind  the  etiology  of 
duodenal  ulcer.  We  have  not  been  able  to  satisfy  ourselves  that 
tliere  is  sufficient  anatomic  difference  to  ex|)lain  the  phenomenon. 
There  is  no  (luestion  but  that  bacteria  can  travel  uj)  the  common 
duct  into  the  gall-bladder.  Bond  found  that  indigo-carmin  placed 
within  the  anus  could  be  detected  in  the  gall-bladder  in  about  forty- 
eight  hours.  It  is  probable  that  this  .sex  difference  is  physiologic 
rather  than  anatomic,  and  possibly  due  in  some  way  to  the  poten- 
tial capacity  of  the  female  liver  to  care  for  mother  and  child. 

In  the  passage  down  the  intestinal  canal  bacteria  increase  in 
numbers  and  in  virulence,  and  in  the  large  intestine  bacterial 
growth  adds  considerably  to  the  bulk  of  the  stool.  The  acid 
change  which  takes  place  in  the  large  intestine  is  probably  caused 
by  germ  life  rather  than  by  intestinal  secretions,  as  the  large  in- 
testine, when  entirely  free  from  feces,  has,  like  the  small  intestine, 
an  alkaline  reaction  (Bond). 

The  problem  of  securing  asepsis  during  operations  upon  the 
upper  abdomen  is  most  interesting.  To  one  who  reads  about  the 
gastric  surgery  of  five  and  ten  years  ago  the  frequency  of  fatal 
results  from  pneumonia  following  operations  upon  the  stomach  is 
most  noticeable,  and  had  various  explanations,  the  anesthetic  and 
the  aspiration  of  gastric  contents  regurgitated  into  the  esophagus 
being  the  most  generally  accepted  hypotheses.  In  Mikulicz's 
clinic  it  was  brought  out  that  part  of  the  venous  blood  from  the 
stomach,  instead  of  passing  through  the  portal  vein  so  that  the 
liver  might  sterilize  it,  returned  directly  through  the  vascular 
anastomoses  about  the  cardiac  orifice,  and  that  this  unsterilized 
blood  was  the  cause  of  a  pneumonia  embolic  in  character. 

Muscatello  demonstrated  that  the  endothelial  serous  hning  of 
the  diaphragmatic  area  was  exceedingly  active  in  absorption,  and, 
based  ujion  this,  Clark  elevated  the  foot  of  the  bed  after  abdonu'nal 
operations  to  insure  rapid  absorption  of  septic  products  and 
prevent   peritonitis.     The   unshed   blood   in   the   vessels   has   no 

VOL.  I — il 


322  WILLIAM   J.    MAYO 

germicidal  properties;  and  this  septic  material,  when  absorbed 
before  being  acted  upon  by  the  proper  tissues,  was  carried  to  the 
lungs,  producing  embolic  pneumonia  of  the  same  variety  that  had 
been  noted  after  operations  on  the  stomach.  Fowler  pointed  out 
that  the  inherited  resistance  to  peritonitis  in  the  pelvis,  which 
had  been  brought  about  by  tubal  diseases  in  women  and  appendi- 
citis in  both  sexes,  caused  absorption  in  this  locality  to  be  slow, 
and  therefore  advised  that,  in  peritoneal  sepsis,  the  head  of  the 
patient's  bed  should  be  raised,  and  a  drainage-tube  introduced 
into  the  pelvis  to  drain  away  the  discharges.  In  connection 
with  general  septic  peritonitis  we  followed  the  Fowler  method, 
except  that  we  raised  the  patient's  head  and  chest  much  higher. 
The  betterment  in  the  mortality  in  peritonitis,  actual  or  impend- 
ing, was  remarkable,  although  it  was  soon  noticed  that  although  the 
patient  did  very  well,  there  was  often  no  drainage  from  the  tube, 
therefore  drainage  was  not  the  sole  factor. 

In  work  upon  the  upper  abdomen  on  the  left  side  any  fluids 
at  once  gravitate  toward  the  diaphragm;  on  the  right,  they  are 
prevented  from  doing  so  by  the  liver.  To  prevent  rapid  absorp- 
tion of  these  unsterilized  products  the  raising  of  the  diaphragmatic 
area  so  as  to  drain  this  material  into  the  pelvis  is  of  the  first  im- 
portance, as  here,  by  means  of  the  omentum  and  pelvic  colon, 
any  septic  particles  can  be  rendered  harmless  by  absorption 
through  the  lymphatics  and  radicals  of  the  portal  vein.  So  far 
as  these  organs  which  lie  within  the  active  radius  of  the  portal 
vein  are  concerned,  the  liver  must  be  looked  upon  as  an  adjuvant 
to  the  lymphatic  glands  in  the  destruction  of  microorganisms. 

The  omentum,  according  to  Dickinson,  is  the  most  important 
agent  in  developing  phagocytosis  and  opsonins;  its  germinating 
endothelium  is  constantly  producing  lymphocytes,  and  is  capable, 
under  proper  stimulation,  of  throwing  both  newly  formed  phago- 
cytes and  those  called  from  a  distance  into  germicidal  action. 
This  process  is  aided  by  the  vermicular  and  swaying  movements 
of  the  intestines,  which,  in  spite  of  gravity,  brings  all  parts  of  the 
small  intestinal  wall  in  contact  with  the  omentum,  the  epiploic 
tags  having  the  same  function  for  the  more  fixed  large  intestine. 


SI  i{(;kuv  of  st().ma<  II   and  assoc  iatkd  vise  era  32.'5 

Dudgeon  and  Sargent  have  shown  that,  from  some  source,  the 
.stai)hyIoc-occu.s  alhus  first  api)cars  in  jjeritoncal  sepsis,  and  rapidly 
|)ro(hues  a  mild  infection,  and  this  furnishes  tlie  necessary  stimulus 
to  the  protective  endothelium,  so  that  the  phagocytes  are  attracted 
in  time  to  destroy  the  more  virulent,  hut  later  developed  l)acteria. 

Bond  has  demonstrated  that  the  plastic  exudate  produced  l>y 
the  stai)hylococcus  albus  protects  the  weakened  endothelium,  and 
prevents  the  microorganisms  passing  directly  into  the  blood- 
stream. When  absorbed  by  sound  endothelium,  bacteria  are 
carried  into  the  lymphatics  and  destroyed. 

In  closing,  let  me  quote  from  Welch's  recent  address  on  the 
occasion  of  the  dedication  of  the  new  buildings  of  the  Harvard 
Medical  School: 

"There  is  a  highly  significant  and  hopeful  scientific  movement 
in  internal  medicine  and  surgery  today,  characterized  by  the 
establishment  of  laboratories  for  clinical  research,  by  the  applica- 
tion of  refined  physical,  chemical,  and  biologic  methods  to  the 
problems  of  diagnosis  and  therapy,  and  by  the  scientific  investiga- 
tions along  broad  lines  of  the  special  problems  furnished  by  the 
living  i)atient." 


r- 


LIVER  AND  GALL-BLADDER 


REPORT  OF  TWO  OPERATIONS  FOR  THE 
RELIEF  OF  GALL-STONES  AND  ONE  FOR 
STRICTURE  OF  THE  COMMON  DUCT  OF 
THE  LIVER* 

WILLIAM    J.    MAYO 


Case  I. — Gall-stone. — E.  B.  B.,  age  tliirty-six.  male.  Ma- 
chinist. History:  For  several  years  liad  sufi'ercd  occasionally 
from  attacks  of  severe  pain  in  the  right  side.  About  one  year  ago 
he  had  one  of  these  attacks,  but  instead  of  recovery,  it  was  fol- 
lowed by  prolonged  illness  with  great  suffering,  and  eventually  an 
abscess  formed  in  the  right  luml)ar  region,  which  was  opened  in 
several  places  by  his  attending  physician. 

December  1,  1890,  he  was  admitted  to  St.  Mary's  Hospital. 
He  was  emaciated,  somewhat  jaundiced,  and  required  opiates  to 
relieve  his  suffering.  On  the  right  side,  extending  from  the  free 
margin  of  the  ribs  to  the  iliac  crest,  was  an  ill-defined  tumor,  and 
in  the  right  groin  a  small  sinus. 

Operation,  December  2,  1890.  Abdominal  section  in  the  right 
linea  semilunaris.  Upon  opening  the  abdominal  cavity  a  mass  of 
adherent  tissue  was  encountered,  surrounding  a  contracted  and 
adherent  gall-bladder  containing  a  single  stone.  A  rubber  drain 
was  placed,  followed  by  free  discharge  of  bile  during  the  next  two 
weeks.  It  was  of  interest  to  note  that  a  laxative  dose  of  sulphate 
of  magnesia  ])roduced  a  copious  discharge  from  the  biliary  fistula, 
but  of  a  watery  character;  calomel  caused  less  discharge,  but  of 
thicker  and  darker  bile.  The  fistula  healed  and  the  patient  was 
discharged  in  three  weeks.  In  a  short  time  he  gained  40  pounds 
in  weight  and  is  now  working  at  his  trade.  The  previous  history 
of  abscess  must  have  been  due  to  empyema  of  the  gall-bladder 
with  external  perforation  and  discharge. 

Case  II. — Gall-stone. — F.  L.,  female,  age  thirty-three. 
Married.     Four    children.     Admitted    to    St.    Mary's    Hospital 

*  Reprinted  from  tlie  "  Xortluvestern  Lanoel,"  April  1,  189^. 

an 


328  WILLIAM    J.    ^L\YO 

June  19,  1891.  Her  attending  physician  gave  us  this  history: 
"Nine  days  after  the  birth  of  last  child,  two  years  ago,  she  was 
seized  with  intense  pain  in  the  region  of  the  gall-bladder  which 
lasted  some  hours.  Since  that  time  she  has  never  been  entirely 
free  from  pain  in  the  right  side,  and  at  frequent  intervals  has  suf- 
fered from  the  most  agonizing  colics  requiring  large  doses  of  mor- 
phin  for  relief.  She  has  never  been  jaundiced.  An  indefinite 
tumor  can  be  felt  in  the  region  of  the  gall-bladder." 

Operation,  June  24,  1891.  Abdominal  section  from  the  costal 
border  of  tenth  rib  downward  three  inches.  The  gall-bladder  was 
found  elongated  and  filled  with  clear  mucus.  Impacted  in  the 
cystic  duct  was  a  single  large  gall-stone  which  was  extracted  after 
great  difficulty.  The  bladder  was  sutured  to  the  abdominal  wall 
and  a  rubber  drain  inserted.  More  or  less  bile  was  discharged 
until  the  fistula  was  healed,  in  fourteen  days.  Patient  recovered 
completely  and  gained  rapidly  in  flesh. 

Case  III. — Stricture  of  Common  Duct  of  Liver. — G.  Z.,  female, 
age  twenty-eight.  Married.  Five  children.  Referred  to  me 
with  this  history:  "After  the  birth  of  the  last  child,  one  year 
ago,  had  some  puerperal  inflammatory  trouble,  with  more  or  less 
jaundice  and  pain  in  the  right  side  ever  since."  Upon  examina- 
tion found  a  badly  lacerated  cervix,  a  cystocele,  a  ruptured  per- 
ineum, and  prolapse  of  enlarged  ovaries  and  tubes  into  Douglas' 
pouch. 

November  9,  1891,  admitted  to  St.  Mary's  Hospital.  The 
uterus  was  cureted  and  irrigated,  cervix  repaired,  an  operation 
made  for  the  cystocele,  and  a  new  perineum  built  up  at  one  opera- 
tion with  catgut  sutures.  This  was  followed  by  marked  improve- 
ment in  her  general  condition  for  about  two  months,  although  a 
certain  amount  of  jaundice  persisted.  From  this  time  on  the 
jaundice  gradually  increased,  with  clay-colored  stools,  etc.  The 
enlarged  and  adherent  ovaries  and  tubes  still  prolapsed  and 
painful. 

February  3,  1892,  exploratory  abdominal  section  was  made 
from  the  costal  end  of  the  right  tenth  rib  do^mward  three  inches. 
On  account  of  the  enormously  enlarged  liver  this  was  extended 
downward;  deep  under  it  the  moderately  distended  gall-bladder 
could  be  felt,  but  on  account  of  the  size  of  the  liver  could  not  be 
drawn  into  the  wound.  Following  the  cystic  duct  to  the  common 
duct  a  mass  of  inflammatory  adhesions  were  encountered  which 
were  torn  loose,  and  although  the  patient  was  thoroughly  anes- 


GALL-STONES    AND   STRICTURE   OF    COMMON    DCCT    OF    LIVER       "i'Z*.) 

thclizcd,  she  at  once  Ix'^an  to  V(jiuit  up  hilc  in  large  (jwantities. 
As  it  was  evident  that  the  duct  was  again  patent,  the  incision  was 
closed  with  sijkworni  gut  and  a  second  section  made  in  the  Hnea 
alba  for  the  removal  of  the  diseased  aj)pendages.  The  tubes  were 
adherent,  the  ovaries  enlarged,  and  small  i)apillomata  were  found 
on  the  right  broad  ligament.  During  the  succeeding  twenty-four 
hours  tlie  patient  vomited  over  two  quarts  of  bile,  and  after  this 
there  was  a  ra{)id  and  uneventful  recovery.  The  jaundice  rapidly 
disappeared,  and  the  patient  was  discharged  in  three  weeks. 


COMPLETE  OBSTRUCTION  OF  THE  COMMON 
DUCT  OF  THE  LIVER.  ANASTOMOSIS  BE- 
TWEEN THE  GALL-BLADDER  AND  JEJU- 
NUM BY  MEANS  OF  MURPHY'S  BUTTON* 

WILLIAM    J.    AND    CHARLES.  H.    MAYO 


Mr.  H.,  age  seventy-one.  Referred  to  us  with  the  following 
history:  "A  number  of  attacks  of  gall-stone  colic  during  the  past 
two  years,  increasing  in  frequency  and  severity.  In  February  of 
this  year  he  had  an  attack  which  was  followed  by  a  light  jaundice; 
this  cleared  up  in  a  short  time.  Three  weeks  later  he  had  another 
attack  of  the  colic,  with  complete  obstruction  of  the  common  duct 
and  almost  constant  pain  since,  with  vomiting,  emaciation,  and 
jaundice  of  the  most  pronounced  type." 

Admitted  to  St.  Mary's  Hospital  May  loth  and  operated  upon 
May  17th.  The  usual  incision  was  made  at  the  right  of  the  rectus 
muscle,  four  inches  in  length.  The  gall-bladder  was  found  deeply 
placed  under  the  liver;  no  stones  could  be  detected. 

The  ducts  were  traced  downward  to  a  point  close  to  the  duo- 
denum, where  the  obstruction  seemed  to  exist.  The  incision  was 
enlarged  by  a  lateral  cut  across  the  rectus  muscle,  but  the  point  of 
obstruction  was  too  deeply  placed  for  any  accurate  manipulation 
or  inspection.  The  gall-bladder,  which  could  not  be  drawn  to  the 
surface,  was  opened,  and  by  means  of  the  Murphy  button  was 
quickly  fastened  to  a  loop  of  the  intestines  as  high  as  practicable. 
The  incision  was  closed,  and  the  patient  made  an  uneventful  re- 
covery. The  jaundice  quickly  disappeared,  and  appetite  and 
strength  returned. 

Considering  his  advanced  age  and  debilitated  condition,  no 
other  method  of  operation  could  have  been  performed  without 
great  or  insurmountable  technical  difficulties. 

*  Reprinted  from  "Northwestern  Lancet,"  June  1,  1893. 


330 


SURGERY  OF  THE   GALL-BLADDER,   CYSTIC 
AND  COMMON  DUCTS,  WITH  REPORT  OF 
SEVEN  CASES  OPERATED  UPON* 

WILLIAM    J.    MAYO 


Mr.  President  and  Members  of  the  Southern  Minnesota  Medical 
Societ7j:  The  rapid  advance  in  abdominal  surgery  during  the  past 
ten  years  has  brought  the  gall-bladder  into  the  operative  field, 
and  in  this  time  more  definite  knowledge  in  regard  to  its  pathology 
and  treatment  has  been  gained  than  during  the  previous  one  hun- 
dred and  sixty  years. 

In  1733  Petit  wrote  the  first  of  his  classic  essays,  and  during 
the  succeeding  ten  years  he  placed  the  pathology  of  gall-bladder 
disease  upon  a  sound  basis,  far  in  advance  of  his  time,  but  his  work 
was  little  appreciated  until  recent  years.  With  the  anatomy  of  the 
gall-bladder,  its  ducts,  and  their  relative  position  to  the  liver  and 
duodenum,  you  are  all  familiar.  The  physiologic  function  of  the 
gall-bladder  is  a  moot  point — the  commonly  accepted  belief  is 
that  it  is  a  storehouse  for  bile  to  be  discharged  during  digestion. 

So  late  an  authority  as  Landois  and  Stirling  authorizes  this  view. 
J.  B.  Murphy  logically  attacks  this  question,  and,  as  a  result  of 
experimental  and  practical  study,  asserts  that  it  has  nearly  the  same 
function  as  the  second  bulb  of  a  syringe  in  regulating  the  flow  of 
bile,  causing  a  steady  stream,  rather  than  an  intermittent  current, 
into  the  duodenum.  Cholelithiasis  is  the  mo^t  common  patho- 
logic condition  of  the  gall-bladder  for  the  relief  of  which  surgery 
offers  the  only  rational  method. 

Gall-stones,  as  a  rule,  are  formed  in  the  gall-bladder  as  a  result 
of  precipitation  and  accretion.     Under  some  circumstances  stones 

*  Reprinted  from  "Jour.  Amer.  Med.  Assoc,"  August  26,  1893. 
331 


332  willia:\i  j.  mayo 

are  also  found  in  the  hepatic  ducts,  especially  in  cancerous  ob- 
struction. The  diagnosis  depends  largely  upon  the  history,  char- 
acter, and  location  of  the  pain,  and  often  physical  examination 
will  reveal  a  tumor  in  this  region.  Jaundice  does  not  appear  unless 
the  common  duct  is  obstructed,  and  is  far  more  common  in  malig- 
nant disease,  and  for  the  same  reason  the  color  of  the  stool,  upon 
which  much  stress  has  been  laid,  is  usually  of  small  importance. 
The  diagnostic  value  of  the  finding  of  gall-stones  passed  with  the 
stool  is  absolute,  but  I  am  inclined  to  think  that  such  passage  of 
gall-stones  is  less  common  than  is  generally  believed,  and  certainly 
the  onset,  duration,  and  cessation  of  a  colic  is  no  indication  that  a 
stone  has  been  passed,  but  meiely  that  the  cystic  duct  has  been 
obstructed,  and  that  either  the  obstruction  has  been  removed  or 
the  bladder  has  exhausted  itself  in  the  effort.  When  olive  oil  in 
large  quantities  was  a  popular  remedy  for  hepatic  colic,  the  soap- 
balls  passed  with  the  stool  and  resulting  from  the  action  of  the 
intestinal  alkalis  upon  the  oil  were  erroneously  supposed  to  be  the 
oflFending  bodies,  and  as  such  were  exhibited  to  the  sufferer  and  his 
friends.  At  the  present  time  we  hear  much  less  about  stones  found 
in  the  feces.  While  stones  may  be  passed  through  the  ducts,  or 
by  ulceration,  into  the  intestine,  externally,  or  into  any  neighbor- 
ing viscus,  or  after  causing  years  of  suffering  remain  quiescent 
without  producing  further  trouble,  such  fortunate  outcome  is  very 
exceptional,  and  in  the  majority  of  instances  operation  is  the  only 
relief  from  a  life  of  suffering  or  death  from  a  complication.  Septic 
infection  of  the  gall-bladder,  either  as  a  result  of  stones  or  from 
extension  upward  through  the  ducts  of  a  septic  process,  is  a  not 
uncommon  occurrence,  and  may  result  either  in  chronic  inflam- 
mation or  empyema.  Fenger  has  done  much  to  elucidate  this 
subject. 

Large  accumulations  in  the  gall-bladder  are  not  infrequently 
confounded  with  right  renal  tumors  or  even  with  ovarian  cysts, 
and  many  such  mistakes  are  recorded,  especially  when  dropsy  of 
the  gall-bladder  exists,  with  great  retention  of  catarrhal  products 
as  a  result  of  duct  obstruction.  Injuries  of  the  gall-bladder  some- 
times occur.      Some  years  ago,  in  my  father's  practice,  I  saw  a  case 


SUIKilOKV    OF    GALL-HLADDKU,    (  VSTK'    AM)    COMMON    DICTS       333 

of  undouhtcfl  rupture  of  the  f^'all-hhulder.  A  hoy  twelve  years  of 
jif^e  was  tlirowu  froui  ji  wa^'on,  the  wheel  passing  partly  on  to  the 
right  side  of  the  ahdonieu.  Ascites  developed,  and  large  (piaiiti- 
ties  of  thin  bile  were  asi)irated  at  different  times  during  a  month. 
Comi)lete  recovery  took  j)lace. 

Operations  upon  the  gall-bladder  may  be  divided  into  tiiree 
general  classes : 

First,  cholecystotomy,  or  the  simple  ofjcning  and  removal  of 
stones.  Lawson  Tait  usually  performs  this  operation  at  one  sit- 
ting, and  the  open  gall-bladder  is  stitched  into  the  incision,  form- 
ing a  temporary  fistula.  Since  bile  is  not  septic  and  does  not  cause 
peritonitis,  other  than  the  adhesive  variety,  slight  biliary  contami- 
nation of  the  i)eritoneum  causes  no  harm,  and  this  open  method 
enables  us  to  manipulate  with  the  finger  inside  the  abdomen, 
outside  of  the  gall-bladder,  which  at  times  is  a  great  aid  in  extract- 
ing stones.  It  also  allows  the  subsequent  escape  of  overlooked 
stones.  If  the  contents  of  the  gall-bladder  be  septic  upon  aspira- 
tion after  the  abdominal  incision  is  made,  it  is  far  safer  to  stitch 
it  into  the  incision  and  delay  opening  for  several  days  until  ad- 
hesive inflammation  has  shut  it  off  from  the  general  cavity. 

Blind  aspiration  of  the  gall-bladder  has  long  been  known  to 
be  of  great  danger;  not,  as  supposed,  on  account  of  the  escape  of 
a  few  drops  of  bile,  but  because  of  the  contents  being  often  septic 
and  the  slight  leakage  setting  up  septic  peritonitis. 

Suture  of  the  gall-bladder  after  opening  and  removal  of  stones 
is  seldom  practised,  and  the  method  is  condemned  as  unsafe. 
This,  however,  is  not  logical — the  whole  cjuestion  of  safety  depends 
on  the  patency  of  the  ducts.  If  there  be  no  obstruction  to  the 
outflow,  so  that  there  will  be  no  tension  within  the  sac,  suture  and 
return  is  a  safe  procedure.  Abbe  tests  the  condition  of  the  ducts 
by  using  a  syringe  and  forcing  water  through  them  into  the  in- 
testine; if  the  fluid  passes  freely,  he  does  not  hesitate  to  trust  to 
immediate  suture  and  return. 

The  second  general  class  is  where  the  gall-bladder  is  removed. 
Langenbeck  first  practised  cholecystectomy  and  formulated  in- 
dications for  its  performance;    he  gives  much  too  wide  a  scope  to 


334  WILLIAM   J.    MAYO 

this  procedure,  and  Greig  Smith  very  properly  hmits  its  applica- 
tion to  single  or  double  stone,  where  the  fundus  of  the  gall-bladder 
cannot  be  sutured  to  the  abdominal  wall,  or  to  cases  wherein  the 
tissues  are  too  thin  or  inflamed  to  bear  a  suture.  It  is  mainly 
practised  by  a  few  Continental  surgeons  and  is  not  a  popular 
operation. 

The  third  class  is  a  very  important  and  often  perplexing  one — 
wherein  obstruction  exists  either  in  the  cystic  or  in  the  common 
duct.  To  suture  such  a  gall-bladder  to  the  abdominal  walls  is 
to  invite  a  permanent  fistula — in  any  case  an  annoyance,  and  if 
complete  obstruction  of  the  common  duct  exists,  the  escape  of 
all  the  bile  externally  leads  to  debility  and  eventually  to  death. 
Fortunately,  the  recent  work  of  J.  Thornton,  Mayo  Robson, 
Robert  Abbe,  and  Charles  McBurney  has  given  us  meth- 
ods of  opening  these  ducts  and  removing  stones  with  either 
suture  of  the  incised  duct  or  drainage.  McBurney  has  success- 
fully opened  the  duodenum  and  shelled  an  impacted  stone  out  of 
the  intestinal  orifice  of  the  common  duct.  There  will  remain  cer- 
tain cases  in  which  the  obstruction  in  the  ducts  cannot  be  removed, 
and  in  these  cases  enterocholecystotomy  is  our  only  hope  of 
success.  Winiwarter  first  sutured  the  gall-bladder  to  the  colon; 
while  this  was  much  better  than  an  external  fistula,  yet  most  of 
the  physiologic  effect  of  the  bile  in  digestion  was  lost.  Gaston, 
of  Georgia,  by  experiments  upon  dogs,  developed  a  complicated 
method  of  suture  to  the  duodenum;  but  it  remained  for  a  brilliant 
young  western  surgeon,  J.  B.  Murphy,  to  invent  his  mechanical 
device  by  means  of  which  an  effectual  back  door  for  the  escape  of 
bile  into  the  duodenum  can  be  safely  and  quickly  made.  In  con- 
clusion, I  append  a  diagrammatic  report  of  seven  cases  in  which  I 
operated  upon  the  gall-bladder  or  its  ducts. 


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GALL-STONE  DISEASE* 

WILLIAM    J.    MAYO 


With  a  view  to  shortening  the  time  necessary  to  present  the 
subject,  I  have  made  but  brief  reference  to  the  history  or  Htera- 
ture  of  gall-stone  disease. 

From  recent  investigations  Webster  estimates  that  10  per  cent, 
of  males,  25  per  cent,  of  females,  and  36  per  cent,  of  the  insane  of 
both  sexes  have  gall-stones. 

From  1500  autopsies  Schroder  estimates  that  12  per  cent,  of 
adults  and  2  per  cent,  of  children  are  afflicted  with  gall-stones. 
Xaunyn  says  that  only  about  1  per  cent,  of  those  who  have  gall- 
stones are  made  aware  of  their  condition  by  symptoms. 

These  statistics  must  be  received  with  a  certain  degree  of 
caution  and  probably  are  high.  Autopsies  performed  in  large 
hospitals  are  of  necessity  made  upon  many  who  were  sick  some 
time  before  their  death,  and  their  lowered  vitality  might  permit 
bacterial  infection  of  the  ducts  and  gall-bladder.  With  the  slug- 
gish bile-current  which  would  be  engendered  by  a  protracted  ill- 
ness this  is  a  condition  which  would  not  exist  in  the  average  in- 
dividual free  from  disease,  and  tends  to  render  these  figures  some- 
what unreliable.  These  factors  are  certainly  important,  as  shown 
by  the  high  average  of  gall-stones  in  the  autopsies  of  the  chronically 
insane.  Kilbourne,  of  the  Second  ]\iinnesota  Hospital  for  the 
Insane,  informs  me  that  they  are  present  in  at  least  a  quarter  of 
the  postmortems  made  at  that  institution. 

Etiology. — Gall-stones  are  usually  formed  in  the  gall-bladder, 
but  under  exceptional  circumstances  may  form  in  the  hepatic 
ducts.     They  are  always  produced  by  the  mucous  membrane  and 

*Reprinted  from  the  "New  York  Med.  Jour.,"  vol.  Ixii,  August  24,  1895. 

336 


GALL-STONE    DISEASE  337 

l)ile,  and  never  from  the  blood.     There  are  two  essential  factors 
in  their  formation:    (1)  Slow  flow  of  bile.     (2)  A  catarrhal  condi- 
tion of  the  mucous  membrane,  frequently  due  to  a  bacterial  in- 
fection, and  usually  caused  by  Bacillus  coli   communis.     Welch 
found  germs  in  the  center  of  gall-stones,  even  when  no  trace  of 
their  presence  could  l)e  detected  in  the  mucous  membrane.     The 
Bacillus  coli  communis  is  a  great  secondary  invader,  waiting  for 
an  entrance  to  be  effected  by  more  active  and  shorter-lived  germs, 
and  it  is  altogether  probable  that  the  original  invading  germ  may 
often    have   disappeared   after   sufficiently    devitalizing   the   epi- 
thelium so  as  to  permit  the  coli  communis  to  effect  a  lodgment. 
As  an  indirect  cause,  the  changing  abdominal  pressure  in  child- 
bearing  women  becomes  an  important  factor  in  influencing  the 
bile  flow,  and  an  accidental  duodenal  inflammation  may  light  up 
an  ascending  catarrh  of  the  bile-tract.     The  frequency  of  bile- 
stone  in  hospital  inmates  may  easily  be  accounted  for  by  their 
sluggish  existence  in  effecting  the  bile  flow  and  lowered  vitality, 
allowing  of  germ  infection.     In  spite  of  the  fact  that  those  physi- 
cally debilitated  or  of  advanced  years  are  most  frequently  affected 
with  gall-stones,  the  majority  of  those  who  seek  relief  from  the 
suffering  engendered  are  otherwise  in  good  health.     I  recently 
removed  132  stones  from  a  girl  under  twenty  years  of  age  with  a 
history  of  colic  for  three  years  previous.     ISIany  similar  operations 
in  the  young  have  been  reported.     It  is  an  interesting  query  as  to 
whether  a  simple  catarrhal  jaundice  might  lay  the  foundation  of 
future  gall-stones.     In  several  instances  I  have  been  able  to  ob- 
tain a  history  of  simple  catarrhal  jaundice,  particularly  in  child- 
hood, followed  by  gall-stone  disease  after  a  lapse  of  many  years. 

The  common  faceted  gall-stones  are  usually  composed  of  bile- 
]>igments  and  cement  substances  from  the  epithelium;  occasion- 
ally of  cholestcrin,  when  they  are  crystalHne  in  fracture,  light- 
colored,  and  often  but  a  single  stone,  or  cholesterin  may  be  the 
nucleus  of  an  ordinary  calculus;  not  rarely  the  stones  are  pure 
bilirubin  and  few  in  number.  There  are  usually  either  a  large 
number  of  small  stones  or  a  small  number  of  large  stones;  all  the 
way  from  1  to  8000  have  been  found.  The  largest  number  I  have 
VOL.  1 — 2i 


338  WILLIAJI  J.    MAYO 

removed  was  402,  from  a  woman  twenty-four  years  of  age.  Twice 
I  have  found  but  a  single  stone. 

The  diagnosis  depends  largely  upon  the  pathologic  condition. 
Ordinarily,  gall-stones  lying  free  in  the  gall-bladder  do  not  produce 
symptoms  of  a  very  definite  nature.  Neuralgic  pains  extending 
up  into  the  region  of  the  liver  and  toward  the  right  shoulder,  with 
indigestion  and  a  certain  degree  of  local  soreness,  may  be  present. 
Under  some  circumstances  the  irritation  of  the  stones  will  aid  an 
infective  process  in  causing  an  ulceration  which  may  end  in  a  con- 
tracted gall-bladder,  vnih  adhesion  to  the  surrounding  viscera,  or 
may  even  expel  the  offending  stone  into  the  intestine,  possibly  to 
cause  intestinal  obstruction  when  of  sufficient  size. 

It  is  altogether  probable  that  many  cases  of  dyspepsia  of  ob- 
scure origin  depend  upon  gall-stones  undiagnosticated. 

Colics  are  not  infrequent,  especially  several  hours  after  eating, 
as  food  passes  down  the  duodenum. 

Obstruction  of  the  cystic  duct,  either  temporarily  or  perma- 
nently, at  once  brings  more  urgent  symptoms.  Colics  are  frequent, 
and  if  the  obstruction  is  complete,  the  pain  is  severe  and  lasts  from 
a  few  moments  to  several  days,  until  either  the  accumulated  fluid 
in  the  gall-bladder  is  forced  past  the  obstruction,  which  ordinarily 
happens,  or  rarely  a  small  stone  may  be  pushed  on,  with  relief. 
At  times,  however,  the  obstruction  is  not  relieved,  and  the  over- 
stretched bladder  is  unable  to  contract  with  such  painful  force  and 
terminates  either  in  a  cystic  accumulation  or,  if  the  infection  is 
sufficiently  active,  eventuates  in  an  empyema  of  the  gall-bladder, 
which  in  turn  may  form  a  fistulous  tract  to  the  surface. 

I  have  examined  two  old  cases  of  gall-bladder  fistula  self-cured 
after  years  of  suffering  from  gall-stone  obstruction,  and  have 
operated  on  two  empyemas  of  the  gall-bladder  due  to  occlusion  of 
the  cystic  duct  by  stones. 

Stones  in  the  cystic  duct  mUst  be  distinguished  from  renal  colic, 
from  diaphragmatic  pleurisy,  from  lead  colic,  and,  when  enlarged, 
from  movable  kidney.  A  little  reflection  will  suggest  the  radical 
points  of  difference.  Temporary  jaundice  may  accompany  stones 
in  either  the  gall-bladder  or  the  cystic  duct.     Under  such  cir- 


GALL-STONE    DISEASE  38i> 

cumstances  it  is  a  valuable  sign,  due  to  swelling,  but  its  absence 
does  not  militate  against  the  diagnosis.  Tenii)orary  jaundice  in 
obstruction  of  the  cystic  duct  should  be  looked  for  with  a  certain 
degree  of  anxiety  as  a  possible  forerunner  of  obstruction  of  the 
common  duct,  which  indicates  a  more  serious  state  of  affairs. 

Stones  in  the  common  duct  are  usually  the  result  of  the  passage 
downward  of  stones  from  the  gall-bladder,  and  not  infrequently 
stones  in  the  gall-bladder  and  cystic  duct  coexist.  The  larger 
size  of  the  common  duct  enables  the  majority  of  calculi  to  pass 
readily  into  the  duodenum,  but  at  times  the  large  size  of  the  stone, 
or  more  frequently  a  small  floating  stone,  more  or  less  obstructs 
this  large  bile-duct  and  produces  a  well-marked  set  of  signs  and 
symptoms.  As  a  rule,  the  obstruction  is  not  complete  at  once,  as 
the  steady  biliary  flow  prevents  early  complete  obstruction.  The 
so-called  "floating  stone,"  which  Fenger  has  done  so  much  to 
elucidate,  is  a  very  interesting  phenomenon,  depending  on  the  fact 
that  the  duodenal  o[)emng  of  the  common  duct  is  smaller  than  the 
duct  itself,  and  that  a  stone  too  large  to  pass  readily  out  may  ob- 
struct the  outflow  of  bile  and  yet  change  its  position  in  the  common 
duct,  permitting  an  intermittent  biliary  outflow,  thus  causing 
temporary  attacks  of  jaundice  and  coHc  which  are  short  in  their 
duration.  There  may  be  a  number  of  colicky  attacks  with  a 
varying  degree  of  jaundice,  which  nearly  or  quite  clears  up,  only 
to  return  in  a  more  marked  degree.  Eventually,  the  obstruction, 
through  irritation  and  inflammatory  swelling  caused  by  the  in- 
fective cholangitis  which  is  prone  to  occur,  brings  on  complete 
cholemia.  The  bile  in  the  blood  rapidly  reduces  the  red  corpuscles 
to  below  3,000,000,  or  even  to  1,500,000,  with  death  from  exhaus- 
tion, or  even  more  rapidly  from  a  suppurative  cholangitis. 

These  cases  are  frecjuently  marked  by  fever,  chills,  and  sweat- 
ing, at  times  of  almost  daily  occurrence.  The  Germans  have 
taught  us  that  this  is  essentially  septic  in  its  nature,  but  the  French 
have  proved  beyond  question  that  it  is  due  to  the  irritation  of  the 
stone  and  the  absorption  of  bile  without  regard  to  an  infective  proc- 
ess. Under  such  circumstances  the  common  duct  is  often  of  huge 
dimensions.     It  has  even  been  opened  under  the  impression  that 


340  WILLIAM  J.    MAYO 

it  was  the  distended  gall-bladder;  its  contents  are,  however,  always 
bilious.  The  gall-bladder,  as  a  rule,  is  small,  and,  while  the  liver 
is  at  first  enlarged,  it  does  not  long  remain  so.  The  jaundice,  with 
its  accompanying  itching,  hypochondriasis,  slow  pulse,  and  white 
stools,  with  the  light  colics,  the  fever,  chills,  sweats,  and  lack  of 
tumor,  aid  in  the  distinction  of  stone  in  the  common  duct.  Ma- 
laria would  not  give  rise  to  the  persistent  jaundice,  while  an  en- 
larged spleen  and  the  presence  of  the  Plasmodium  malarise  would 
aid  in  the  diagnosis. 

From  cancerous  obstruction  due  to  tumor  of  the  liver,  pancreas, 
or  duodenum  the  diagnosis  may  be  difficult,  particularly  in  the 
later  stages.  It  should  be  borne  in  mind  that,  as  a  rule,  the  pres- 
ence of  a  tumor  with  jaundice  is  against  simple  stone  in  the  com- 
mon duct;  while,  as  pointed  out  by  Mayo  Robson,  a  history  of 
slight  colics  and  intermittent  jaundice  in  the  early  stages,  wdth 
fever,  chills,  sweats,  and  without  tumor,  favors  simple  stone  ob- 
struction. 

The  mistake  of  diagnosticating  a  tumor  in  case  a  tongue  of 
liver  projects  downward  in  this  region,  as  described  by  Riedel  as 
a  not  uncommon  phenomenon,  should  not  be  made.  I  have  oper- 
ated twice  on  these  indications,  and  have  found  them  a  reliable 
means  of  diagnosis.  Fagge,  in  his  great  work  on  "Practice," 
long  ago  pointed  out  that  cancer  of  the  liver  and  biliary  ducts  was 
often  complicated  wdth  gall-stones,  and  correctly  interpreted  their 
presence  as  the  exciting  cause  of  the  cancer,  rather  than  an  acci- 
dental compKcation.  Musser  estimates  that  90  per  cent,  of 
persons  with  cancer  affecting  the  liver  also  have  gall-stones,  and 
the  danger  of  the  calculi  acting  as  an  irritative  in  the  production 
of  cancer  should  be  borne  in  mind.  Twice  within  a  year  I  have 
operated  in  cases  of  cancer  complicated  \\dth  gall-stones;  in  each, 
jaundice  with  an  appreciable  tumor  gave  indications  of  the  fatal 
complication,  while  a  marked  history  of  gall-stone  disease  ante- 
dated the  final  illness  by  many  years. 

The  prognosis  then  depends  much  upon  the  situation  of  the 
stones.  Stones  lying  free  in  the  gall-bladder  may  never  give  a 
diagnostic  symptom  of  their  presence,  although  septic  processes 


(;all-stone  diskase  .'J41 

in  the  ^'all-hladdcr  diu'  to  an  inft'flion  or  retention  may  present, 
urgent  syniptcjins  for  relief.  Stones  in  the  cystic  duet,  l)y  prcKlue- 
ing  changes,  in  the  gall-bhidder,  exhausting  colics,  or  ulceration, 
require  relief.  Stones  in  the  common  duct  are  urgent  and  demand 
prompt  removal. 

The  chances  of  stones  jiassing  into  the  intestine  have  been 
greatly  overestimated,  because  of  the  prevalent  idea  that  a  colic 
means  the  j)assage  of  a  stone,  which  is  seldom  the  case,  and  even 
if  it  did  pass,  it  must  be  a  small  one,  and  the  history  of  this  class 
of  patients  is  that  in  the  small  stone  cases  there  are  many  stones, 
and  there  is  no  guarantee  against  future  trouble.  The  idea  of  the 
frequency  of  the  expulsion  of  gall-stones  has  also  been  due  to 
washing  the  stools  and  finding  small  bodies  supposed  to  be  calculi, 
or  the  giving  of  some  bland  oil,  such  as  olive,  which  forms  soap- 
balls  with  the  intestinal  alkalis,  and  these  are  many  times  ex- 
hibited as  the  offending  bodies.  The  possibility  of  secondary 
cancer  should  also  be  taken  into  account  in  the  prognosis. 

Treatment  of  Gall-stone  Disease. — It  can  be  asserted  without 
fear  of  contradiction  that  there  is  no  medical  treatment  for  gall- 
stones: it  is  wholly  surgical.  We  cannot  dissolve  these  calculi 
in  the  living  body,  although  much  can  be  done  for  the  relief  of  the 
disease  in  a  non-operative  way  when  the  stones  are  confined  to 
the  gall-bladder.  The  internal  administration  of  remedies  which 
increase  the  rapidity  of  the  biliary  flow  has  a  deserved  reputation 
in  preventing  the  formation  of  stones,  phosphate  of  sodium,  or  a 
course  at  the  Carlsbad  or  other  saline  springs,  being  most  popular. 
As  the  passage  of  food  through  the  duodenum  is  particularly  apt 
to  bring  on  a  colic,  the  use  of  remedies  calculated  to  allay  any 
existing  duodenal  catarrh  may  be  of  aid,  and  the  avoidance  of 
such  articles  of  diet  which  the  patient  soon  learns  to  know  as 
most  liable  to  start  a  colic.  Glycerin  has  of  late  been  lauded, 
as  well  as  many  preparations  of  enterprising  drug  firms.  Such 
allegations  are  supported  by  uncertain  evidence,  derived  from  the 
fact  that  intervals  of  quiescence  are  frequent,  or  based  wholly 
upon  the  imagination  of  the  owner  of  the  drug.  Olive  oil  a  I 
one  time  had  a  great  reputation,  the  examination   of  the   stools 


342  WILLIAM   J.    MAYO 

after  its  administration  showing  quantities  of  soap-balls  formed 
by  the  action  of  the  intestinal  alkalis  and  shaped  by  vermicular 
action.  For  the  rehef  of  pain  caused  by  a  temporary  blocking  of 
the  cystic-duct  opening  hypodermic  injections  of  morphin,  or 
even  chloroform,  may  be  required. 

Surgical  Treatment. — While,  as  a  matter  of  course,  even  the 
most  enthusiastic  surgeon  would  not  advise  operation  in  every 
case  of  gall-stone  disease,  it  can  be  said  that,  other  things  being 
equal,  every  case  of  gall-stone  disease  causing  marked  symptoms 
should  be  relieved  by  removal  of  the  calcuh,  and  if  obstruction  of 
the  cystic  duct  has  taken  place,  an  operation  is  imperative,  while 
if  the  stone  is  in  the  common  duct,  delay  in  operating  would  be 
criminal.  The  situation  of  the  gall-bladder,  as  shown  by  Hamil- 
ton, is  very  definite  in  the  male,  but  has  a  somewhat  larger  range 
of  position  in  child-bearing  women,  for  obvious  reasons.  The  in- 
cision for  gall-bladder  operations  is  a  matter  of  some  importance. 
Lawson  Tait,  the  leader  in  this  as  in  other  branches  of  abdominal 
surgery,  prefers  a  vertical  incision  downward  from  the  tip  of  the 
cartilage  of  the  tenth  rib.  Musser  and  Keen  make  use  of  an  in- 
cision skirting  the  margin  of  the  costal  cartilage.  In  a  recent  ar- 
ticle on  Hernia  in  the  "Annals  of  Surgery,"  Greig  Smith  calls 
attention  to  the  advantages  of  an  incision  in  the  course  of  the  ex- 
ternal oblique  muscle,  on  a  line  running  from  the  tip  of  the  tenth 
cartilage  toward  the  umbilicus,  with  separation  of  the  fibers  of  the 
internal  oblique,  as  giving  a  better  closure  of  the  wound,  the  essen- 
tial principle  being  the  same  as  McBurney's  incision  for  chronic 
appendicitis.  Having  observed  a  well-marked  hernia  following 
the  vertical  cut,  I  practised  this  incision  in  two  instances  to  ad- 
vantage. For  work  on  the  ducts,  an  additional  incision  along  the 
costal  margin  enables  an  ample  flap  to  be  turned  downward  and 
inward,  giving  a  large  amount  of  working  space.  Cholecystotomy 
is  indicated  for  the  removal  of  stones  from  the  gall-bladder,  and 
is  an  important  part  of  the  method  of  elevating  stones  from  the 
cystic  duct,  not  only  as  an  aid  in  the  removal  of  the  impacted 
stones,  but  also  as  there  may  be  stones  behind  the  obstruction. 
Needling  the  gall-bladder  for  diagnosis,  as  originally  done  by  Har- 


(JALL-STONE    DISEASE  .'US 

ley,  is  useless  and  (Itm^croiis,  ciLher  before  or  after  tlie  abdomen  is 
opened.  Even  with  the  finger  in  the  abdomen  stones  cannot  al- 
ways be  felt,  through  the  gall-bladder  wall,  and  it  is  aI\va3^s  neces- 
sary to  open  this  viscus  before  their  absence  is  decided  Uf)on. 

Some  years  ago,  before  modern  methods  of  protecting  the  peri- 
toneal cavity  temporarily  with  gauze  were  perfected,  many  sur- 
geons fastened  the  gall-bladder  in  the  abdominal  wound  and  waited 
several  days  for  adhesions  to  shut  the  free  peritoneal  cavity  off. 
This  has  the  great  disadvantage  of  not  being  able  to  use  the  finger 
in  the  abdominal  cavity  outside  the  gall-bladder  and  ducts  as  an 
aid  in  coaxing  the  calculus  from  its  bed,  particularly  when  im- 
pacted. It  is  probably  the  rule  that  if  the  contents  of  the  gall- 
bladder are  actively  infectious,  it  is  already  adherent,  and  under 
such  circumstances,  if  not  so  adherent,  it  would  be  wise  to  make  a 
secondary  opening.  In  two  cases  in  which  the  gall-bladder  was 
filled  with  the  products  of  an  infective  inflammation  as  well  as 
stones,  I  found  it  already  adherent,  which  made  the  operation 
largely  extraperitoneal,  by  reason  of  the  adliesions  to  the  omentum, 
colon,  and  parietal  peritoneum.  In  his  original  operation  Bobbs 
closed  the  wound  in  the  gall-bladder  with  sutures  and  dropped  it 
back,  and  this  so-called  "ideal"  operation  has  had  some  adherents, 
but  the  objections  to  it  are  weighty. 

The  following  points  are  urged  against  suture  of  the  gall- 
bladder in  the  wound: 

1.  The  chances  of  a  permanent  fistula;  but  if  the  ducts  are 
open,  this  should  not  take  place.  In  one  of  my  early  operations 
prolonged  biliary  leakage  gave  some  annoyance,  and  vigorous 
cauterization  was  necessary  for  cicatrization.  This  was  due  to  a 
too  accurate  suture  of  the  mucous  membrane  to  the  skin,  leaving 
practically  a  mucocutaneous  mouth.  In  all  my  later  operations 
I  have  used  the  peritoneal  and  muscular  coats  of  the  gall-bladder, 
and  carefully  avoided  the  mucous  membrane  in  the  suture,  thus 
getting  a  larger  cicatrizing  area  between  it  and  the  skin,  with  the 
result  that  the  fistulas  have  rapidly  closed. 

2.  The  danger  of  hernia  by  the  interposition  of  the  gall-bladder 
between  the  margins  of  the  incision.     In  'rZo  of  the  l28  cases  of  ini- 


344  WILLIAIVI   J.    aiAYO 

mediate  suture  reported  by  Elliot  gauze  drainage  was  employed, 
and  this  would  have  a  parallel  effect.  In  favor  of  drainage  of  the 
gall-bladder  is  the  important  fact  that  not  infrequently  stones  will 
be  found  extruded  into  the  dressings,  although  all  were  supposed 
to  have  been  removed. 

In  one  of  my  cases,  after  removing  about  200  small  stones, 
during  the  next  week  over  50  more  were  discharged:  in  another 
case  2  stones  were  found  in  the  dressings  at  the  end  of  the  week. 
Drainage  also  cures  the  catarrhal  condition  of  the  gall-bladder,  as 
when  sutured  into  the  wound  it  usually  shrinks  up  into  a  fibrous 
cord,  or  at  least  by  forcible  elevation  of  its  normally  dependent 
fundus  furnishes  free  drainage  and  prevents  any  retention  of  fluids 
or  new  stone  formation. 

At  times  it  may  be  impossible  to  bring  a  contracted  gall- 
bladder to  the  surface,  but  experience  has  shown  that  it  can  be 
safely  drained  through  the  incision,  using  the  omentum,  if  possible, 
in  forming  a  channel. 

Morison  drains  through  the  loin  near  the  hepatic  flexure  of 
the  colon,  and  maintains  that  fluids  naturally  gravitate  to  this 
point.  I  can  imagine  a  case  of  gall-stone  in  which  the  certainty 
of  complete  removal  and  the  healthy  condition  of  the  walls  of  the 
gall-bladder  might  render  suture  and  dropping  back  good  surgery, 
but,  as  yet,  I  have  not  met  with  such  a  case.  The  removal  of 
impacted  stones  from  the  cystic  duct  is  a  matter  of  great  difiiculty, 
and  may  require  incision  of  the  duct.  In  2  out  of  3  such  cases  I 
have  been  able  to  push  the  stone  back  into  the  bladder.  In  the 
third  I  incised  the  duct  and  removed  the  stone,  but,  being  unable 
to  suture  the  empty  duct  with  any  degree  of  accuracy,  drained 
with  a  rubber  drain  and  suture  of  iodoform  gauze  to  the  proper 
place  by  means  of  fine  catgut  which  will  hold  long  enough  to  cause 
adhesions  at  the  desired  point,  and  yet  be  absorbed  sufficiently 
early  to  allow  removal  of  the  gauze. 

The  value  of  fine  catgut  for  the  accurate  placing  of  deep  gauze 
tampons  cannot  be  overestimated.  The  removal  of  stones  from 
the  common  duct  is  often  an  operation  of  the  greatest  difficulty, 
and  in  the  case  of  a  floating  stone  may  be  impossible. 


GALL-STONE    DISEASE  34.5 

Fcngcr,  in  two  oases,  introduced  his  finder  into  tlie  diluted  (-(jni- 
inon  duet,  hnt  was  uiiahle  to  reach  a  floating  stone  which  retreated 
upward  into  the  hepatic  ducts. 

If  the  stone  can  be  found,  the  duet  should  be  incised  over  it, 
and  before  removal  the  inij)ortant  suggestion  of  Elliot  should  be 
carried  out — that  is,  the  placing  of  sutures  after  incision  while  the 
stone  is  yet  in  position.  It  is  exceedingly  difficult  to  i)lace  the 
sutures  after  removal  of  the  stone. 

In  one  of  two  eases  of  stone  in  the  common  duct  I  could  not 
find  the  stone,  and  performed  choleeystenterostomy  with  the 
Murphy  button.  The  patient,  an  old  man,  completely  jaundiced, 
is  now  alive  and  well,  two  years  after  the  operation.  The  opera- 
tion of  choleeystenterostomy  in  obstruction  of  the  common  duct 
by  means  of  Murphy's  mechanical  device  is  of  inestimable  value, 
and  in  the  feeble  cholemic  condition  which  this  form  of  obstruc- 
tion fiuickly  produces  in  the  victim  is  a  life-saving  procedure. 

The  Germans  still  do  Winiwarter's  suture  method  of  chole- 
eystenterostomy. The  use  of  this  method  for  routine  treatment 
of  all  forms  of  gall-stone  is  not  logical,  and  with  few  exceptions 
the  union  of  the  gall-bladder  and  intestine  should  be  confined  to 
complete  obstruction  of  the  common  duct.  For  simple  stones 
without  their  removal,  and  for  obstruction  in  the  cystic  duct,  it 
cannot  be  considered  good  surgery.  Cholecj^stectomy  was  ad- 
vocated by  Langenbeck,  but  is  now  seldom  done  as  a  matter  of 
choice.  At  times  a  small,  friable  gall-bladder  which  cannot  be 
brought  to  the  surface  is  tied  off,  and  the  region  thoroughly 
drained  to  meet  a  pressing  indication. 

Spasmodic  attempts  to  popularize  removal  of  the  gall-bladder 
have  been  made  at  various  times,  but  as  a  routine  procedure  it  is 
uncertain.  I  have  performed  16  operations  for  gall-stones — 8  for 
simple  removal  of  unimpacted  stones,  3  for  stones  in  an  empyemic 
or  cystic  gall-bladder,  3  for  stones  impacted  in  the  cystic  duct,  and 
2  for  stones  obstructing  the  common  duct — with  1  death,  in  a  case 
of  suppurating  gall-bladder,  with  perforation  and  septic  periton- 
itis already  present.  The  patient  died  within  a  few  hours  follow- 
ing operation. 


A  CASE  OF  GUNSHOT  WOUND  OF  THE  LIVER. 
IMMEDIATE  OPERATION.     RECOVERY* 

WILLIAM    J.    MAYO 


H.  C,  a  lad  of  fourteen  years,  while  hunting  October  3,  1896, 
was  shot  accidentally  by  a  companion  with  a  rifle.  The  rifle  was 
only  a  foot  away,  and  the  bullet  entered  the  body  one  inch  below 
the  ensiform  cartilage  and  three-fourth  inch  to  the  right  of  the 
median  line.     There  was  no  wound  of  exit. 

The  accident  occurred  some  distance  from  the  city  at  about 
12  M.,  and  the  patient  was  brought  to  the  hospital  at  3  p.  m.  in  a 
condition  of  shock.  Temperature  was  subnormal;  pulse,  118, 
and  very  feeble.  He  complained  of  some  pain  in  the  abdomen, 
which  was  contracted  and  rigid.  He  was  somewhat  nauseated, 
and  had  vomited  once  after  the  accident,  but  without  evidence  of 
blood. 

Measures  were  taken  to  relieve  the  shock,  and  the  patient  was 
at  once  prepared  for  operation.  Ether  was  administered  at  4  p.  m., 
just  four  hours  after  the  injury. 

An  incision  was  made  from  the  tip  of  the  ensiform  cartilage  to 
the  umbilicus,  opening  the  abdominal  cavity  freely.  A  lateral 
cut  was  then  made  to  the  right,  so  as  to  include  the  wound  of  en- 
trance. The  bullet  had  cut  half  of  its  diameter  into  the  edge  of 
the  right  costal  arch,  and  entered  the  liver  just  at  the  inner  edge 
of  the  right  suspensory  ligament. 

On  the  surface  of  the  liver  was  found  a  bit  of  his  flannel  shirt, 
which  had  evidently  been  caught  against  the  costal  arch  and  cut 
out  like  a  pouch.  From  the  hole  in  the  liver  dark  blood  was 
welling  up,  and  the  abdomen  was  filled  with  blood.     The  liver,  as 

*  Reprinted  from  "New  York  Med.  Jour.,"  March  20,  1897. 
346 


(ASK    OF    (U'NSIIOT    WULNU    Oi'    Ll\  KK  li47 

is  usiKil  in  youiij;  adults,  was  very  large,  extendiiifr  downward 
nearly  to  the  uinhilicus.  A  i)rol)e  passed  directly  backward  six 
inches  was  arrested  by  the  posterior  abdominal  ^\all. 

With  a  finj^er  introduced  under  the  gastrohejjatic  ligament 
through  Winslow's  foramen,  search  was  made  in  the  lesser  cavity 
of  the  peritoneum  for  the  probe  which  had  been  left  in  position, 
but  it  could  not  be  felt.  A  i)iecc  of  iodoform  gauze  was  i)assed 
along  the  finger  under  the  lesser  omentum  and  brought  out  at  the 
lower  angle  of  the  incision  to  drain  this  space.  With  a  finger  the 
wound  in  the  liver  was  rapidly  searched  for  foreign  bodies,  and 
then  packed  deeply  with  iodoform  gauze,  bringing  it  to  the  sur- 
face in  the  track  of  the  bullet.     The  bleeding  was  checked  at  once. 

The  abdomen  was  not  irrigated,  the  effused  blood  being  left 
for  absorption.  The  abdominal  incision  was  closed,  except  at  the 
points  of  gauze  drainage.  After  vigorous  stimulation  the  patient 
rallied.  The  drains  were  removed  in  six  days,  and  he  left  the 
hospital  fully  recovered  in  twenty  days. 

Eight  weeks  after  the  injury  an  .r-ray  photograph  was  taken 
and  the  bullet  located  in  the  muscles  of  the  back.  It  gave  the 
boy  no  trouble  and  was  not  interfered  with. 


SOME  OBSERVATIONS  ON  THE  SURGERY  OF 
THE  GALL-BLADDER  AND  THE 
BILE-DUCTS* 

WILLIAM    J.    MAYO 


During  the  past  eight  years  105  operations  have  been  made  on 
the  gall-bladder  and  the  bile-ducts  in  St.  Mary's  Hospital . 

For  gall-stones  in  the  gall-bladder  or  cystic  duct,  or  both, 
cholecystotomy  was  performed  64  times,  with  1  death;  4  of  these 
cases  required  separate  incision  of  the  cystic  duct  for  the  removal 
of  an  impacted  stone,  and  in  3  cases  soft  stones  in  the  duct  were 
crushed. 

Four  of  the  64  cases  required  secondary  operations:  2  for 
the  removal  of  gall-stones  overlooked  at  the  primary  operation; 
one  for  the  relief  of  biliary  fistula,  probably  due  to  putting  the  gall- 
bladder on  the  stretch  by  too  low  an  attachment  to  the  external 
incision. 

The  fourth  had  a  cystic  accumulation,  caused  by  a  stricture 
in  the  cystic  duct.  In  addition,  3  cases  had  more  or  less  trouble 
after  the  healing  of  the  fistula,  due  to  inefficient  drainage  through 
the  cystic  duct,  and  in  two  of  these  the  wound  reopened  several 
times,  with  discharge  of  retained  secretion. 

In  8  cases  cholecystotomy  was  made  for  the  relief  of  infection 
of  the  gall-bladder  or  the  ducts,  or  both,  wdth  one  death  fourteen 
days  after  an  operation  for  suppurative  cholangitis. 

Two  cases  of  infective  cholangitis  were  operated  upon;  both 
recovered.  In  these  2  cases  the  gall-bladder  was  shrunken  and 
contained  no  stones,  although  there  probably  had  been  a  previous 
cholelithiasis.     In  the  remaining  5  cases  the  suppurative  process 

*Reprinted  from  "Annals  of  Surgery,"  October,  1899. 
348 


suitGEUY  or  c;all-ijlai)iji:u  and  uilk-ducts  3U) 

was  confined  to  the  ^all-hladdcr,  and  in  4  stones  were  present.  In 
1  a  secondary  operation  has  since  been  performed  for  retention 
cyst,  and  in  another  there  is  a  mucous  fistula  present  at  this  time. 
It  will  be  noted  that,  in  the  total  of  72  cases  of  cholecystotomy 
there  were  2  deaths,  and  7  cases  in  which  the  gall-bladder  continued 
to  give  trouble  from  causes  not  connected  with  the  stone-formation. 

In  all  these  cases  of  failure  to  cure  by  cholecystotomy  there 
has  been  an  obstruction  to  drainage  through  the  cystic  duct.  The 
ol)stacle  is  usually  a  stricture  due  to  an  ulceration  in  the  duct  from 
prolonged  lodgment  of  a  stone  or,  as  pointed  out  by  Fenger,  to 
angulation  of  the  duct.  The  mucous  membrane  continues  to  se- 
crete, and  colicky  pains  attend  the  forced  passage  of  the  secretions. 

Harris  has  pointed  out  that  the  small  gall-bladder  firmly  con- 
tracted on  stones  is  especially  liable  to  subsequent  attack  of  re- 
current regional  peritonitis,  and  this  has  been  our  experience. 
After  the  removal  of  the  external  drainage  the  thickened  walls  of 
the  gall-bladder  continue  to  contract,  interfering  with  the  drainage 
through  the  ducts  from  the  islands  of  mucous  membrane  not  pre- 
viously destroyed,  and  a  condition  results  resembling  a  chronic 
appendicitis  in  many  respects.  In  such  cases,  and  in  all  cases  in 
which  a  stricture  is  already  present  in  the  cystic  duct,  cholecys- 
tectomy should  be  performed. 

In  the  7  cases  in  which  further  trouble  was  experienced  chole- 
cystectomy, or  removal  of  the  mucous  membrane  of  the  gall- 
bladder, which  amounts  to  the  same  thing,  would  have  resulted  in 
cure. 

Cholecystectomy  was  made  4  times — all  the  patients  recovered: 
once  as  a  primary  operation  in  a  case  of  acute  gangrenous  in- 
flammation of  the  gall-bladder,  once  for  biliary  fistula,  and  twice 
for  recurrent  cholecystitis. 

Choledochotomy  was  performed  for  stones  in  the  common 
duct  11  times,  with  recovery  in  each  instance.  In  8  of  these  cases 
the  gall-bladder  was  shrunken,  and  in  only  5  did  it  also  contain 
stones.  One  was  a  typical  example  of  the  ball-valve  stone  de- 
scribed by  Fenger;  all  these  cases  have  remained  well,  the  gall- 
bladder giving  no  further  trouble.     The  fact  that  the  cystic  duct 


350  WILLIAM   J.    MAYO 

was  able  to  pass  the  stone  would  indicate  that  drainage  was  free. 
As  previously  remarked,  such  a  gall-bladder  firmly  contracted  upon 
the  stone  would  argue  to  the  contrary,  and  clinical  experience  dem- 
onstrates the  correctness  of  this  view. 

Cholecystenterostomy  was  made  once  with  the  Murphy  button 
for  a  stricture  of  the  common  duct  which  had  caused  jaundice  for 
eight  months  in  a  man  seventy-one  years  of  age.  The  patient  re- 
covered, and  remained  well  for  more  than  six  years,  eventually 
dying  of  other  causes. 

In  3  cases  a  gall-bladder,  fastened  by  adhesions  to  the  adjacent 
viscera,  gave  rise  to  pain  and  gastric  symptoms.  In  these  cases 
the  history  of  colics  in  previous  years  warranted  the  belief  that 
stones  had  once  been  present.  Liberation  of  the  adhesions  relieved 
the  symptoms. 

In  7  cases  an  exploratory  incision  was  negative,  no  gall-stones 
being  present.  In  2  of  these  a  diseased  appendix  was  found  to  be 
the  source  of  trouble.  Dietl's  crisis  from  a  movable  kidney  proved 
to  be  the  real  difficulty  in  another,  and  in  4  no  cause  for  the  symp- 
toms could  be  discovered.  This  gives  98  operations  and  explora- 
tions upon  the  gall-bladder  and  ducts  for  non-malignant  disease, 
with  a  mortality  of  2. 

For  malignant  disease  involving  the  bile-tract  7  operations  were 
performed,  4  cholecystotomies,  1  cholecystenterostomy,  and  2 
exploratory  incisions,  with  3  deaths.  In  5  of  these  cases  jaundice 
was  present  and  the  gall-bladder  was  distended  with  clear  mucus. 
In  3  a  small  quantity  of  bile-stained  serum  escaped  on  opening  the 
peritoneal  cavity. 

The  results  merely  substantiate  the  well-known  fact  that,  in 
the  great  majority  of  cases  of  malignant  disease  involving  the  bil- 
iary apparatus,  operation  is  contraindicated. 

The  straight  incision  of  Tait,  either  through  the  rectus  muscle 
or  at  its  outer  margin,  was  employed  until  two  years  ago,  since 
which  time  the  Bevan  incision  has  been  made  use  of  in  the  majority 
of  cases.  The  latter  gives  a  larger  space  for  work  and  is  easy  of 
closure.  The  so-called  "ideal"  operation  of  cholecystotomy  with 
immediate  suture  has  not  been  employed.     Theoretically,  it  does 


SURGERY    OF    GALL-KLADDKR    AM)    niLP>DUCT.S  .'{.>  1 

not  appear  to  be  a  scientific  procedure,  as  it  does  not  furnish  drain- 
age to  the  accompanying  cholecystitis,  and  there  is  nothing  to  pre- 
vent the  formation  of  stones  in  the  future. 

The  normal  position  of  the  gall-bladder  makes  the  fundus  de- 
pendent. Given  an  infection  with  a  sluggish  bile  current  and  the 
deposit  of  sediment,  and  formation  of  stone  is  mechanically  easy. 
It  would  seem  that  the  cases  of  typical  colics  in  which  stones  are 
not  found  migiit  be  due  to  the  occasional  emptying  of  the  gall- 
bladder by  muscular  contraction,  causing  great  pain  as  the  sedi- 
ment or  nmcus  passes.  When  the  fundus  is  sutured  into  the  ex- 
ternal wound,  the  necessary  elevation  brings  the  cystic  duct  more 
nearly  at  the  bottom,  so  that  the  mechanical  conditions  in  pre- 
venting sedimentation  and  stone-formation  are  even  better  than 
in  the  normal  individual.  Our  observation  has  been  that  the  ca.ses 
of  cholecystotomy  in  which  all  the  stones  were  removed  and  the 
ducts  free  have  had  no  further  trouble,  and  this  without  any  changes 
in  the  habits  of  the  individual,  which  might  contribute  to  the 
result.  The  fixation  and  elevation  of  the  fundus  permanently 
drain  the  gall-bladder  through  the  cystic  duct,  which  has  become 
the  most  dependent  part,  and  gravity  alone  is  effectual. 

The  gall-bladder  was  opened  and  the  stones  removed  before 
suturing  it  into  the  incision,  with  the  exception  of  two  cases  of 
suppurative  cholecystitis.  The  after-treatment  was  prolonged  in 
these  two  cases,  and  the  writer  believes,  notwithstanding  the  suc- 
cess of  Riedel  with  this  method,  that  with  proper  protection  even 
septic  cases  should  be  opened  and  carefullj'^  examined  at  the 
primary  operation.  The  cystic  obstruction  frequently  depends 
upon  a  stone,  which  can  be  removed  much  better  at  this  time  than 
later.  If  the  gall-bladder  is  adherent  to  the  omentum,  colon,  or 
other  viscera,  the  adhesions  are  freed  a  sufficient  space  on  the 
fundus  for  manipulation,  and  on  the  inner  side  to  permit  careful 
exploration  of  the  ducts  and  to  facilitate  the  removal  of  stones. 

No  attempt  has  been  made  to  free  the  adhesions  at  every 
point,  as  this  would  open  up  further  avenues  of  infection  and 
destroy  temporary  barriers  of  adhesions.  If  the  cause  of  the 
cholecystitis  is  removed,  the  adhesions  usually  disappear  in  time, 


352  WILLIAM   J.    AL\YO 

and  if  separated,  reform  temporarily.  Should  the  history  indicate 
that  these  adhesions  have  been  causing  trouble,  it  would,  of  course, 
be  best  to  di^^de  them  and  cover  the  raw  surface  by  suturing  to 
prevent  reformation. 

It  is  a  frequent  experience  to  find  a  contracted  gall-bladder 
deep  under  the  hver,  which  it  is  impossible  to  suture  into  the 
wound.  In  such  cases  we  have  found  a  very  satisfactory  method 
of  drainage  to  be  as  follows : 

Two  or  more  long  sutures  of  fine  catgut  are  passed  through  the 
walls  of  the  gall-bladder  below  the  opening.  A  well  of  gauze  strips 
2  inches  in  width  is  now  formed  by  passing  one  or  more  doubled 
thicknesses  down  just  outside  of  the  gall-bladder,  and  tying  in 
place  with  the  catgut  sutures.  The  side  of  a  rubber  drain  is  caught 
at  a  Httle  distance  from  its  extremity  by  one  of  the  threads  of  cat- 
gut on  a  needle,  and  the  tube  is  then  passed  into  the  gall-bladder 
and  tied  in  place.  This  firmly  anchors  the  drains  in  position  and 
prevents  displacement;  the  external  incision  is  partly  closed  up  to 
the  drainage  in  the  usual  manner.  The  catgut  is  absorbed  before 
it  is  necessary  to  remove  the  drains. 

We  have  not  hesitated  to  crush  soft  stones  in  the  cystic  duct 
with  the  fingers;  but  if  the  deposits  were  hard,  the  duct  was 
opened  by  incision  and  the  stones  removed.  The  success  of  Mayo 
Robson  in  crushing  stones  impacted  in  the  bile-ducts  is  encourag- 
ing, and  probably  could  have  been  done  with  advantage  in  some  of 
the  cases  in  which  cutting  was  resorted  to. 

The  time  of  drainage  of  the  gall-bladder  has  varied  with  the 
case,  if  one  is  certain  that  all  stones  have  been  removed,  and  the 
walls  are  not  greatly  thickened  nor  adherent,  and  bile  flows  freely 
at  once,  three  or  four  days  is  sufficient. 

If  there  have  been  many  small  stones  or  much  fragmentation 
of  soft  ones,  a  quantity  of  bile-sand,  or  evidence  of  prolonged  in- 
flammation, one  or  more  weeks,  is  necessary. 

The  suggestion  of  Knut  Hoegh  that  suturing  at  a  low  point  in 
the  incision  favors  fistula  formation  is  probably  true,  as  it  does  not 
properly  elevate  the  fundus  and  should  be  avoided. 

Of  the  11  cases  in  which  stones  were  removed  from  the  common 


SURGKRY    OF    CALL-RLADDrOR    AND    RIIJC-DUCTS  3.53 

(liict,  in  only  4  was  an  attcnij)t  made  to  .suture  the  duct;  in  2  of 
these  there  was  no  leakage.  Seven  cases  were  treated  by  drainage 
without  suture,  and  the  recovery  was  just  as  prompt  as  in  the 
sutured  cases.  The  stone  is  isolated,  and  the  duct  held  between 
the  finger  and  tluimh.  By  pressing  the  stone  firmly  against  the 
duct-wall  and  tiicn  relaxing  it,  veins  can  sometimes  be  located — 
as  they  fill — and  avoided.  A  longitudinal  incision  is  made,  and  the 
stone  caused  to  present.  Following  the  suggestion  of  Elliot,  the 
stone  is  used  like  a  stocking  ball  for  the  placing  of  a  lateral  suture 
of  fine  catgut  each  side  of  the  opening;  it  is  then  removed  and 
search  made  for  others,  which  are  removed,  if  found.  A  strip  of 
gauze  two  inches  wide  is  carried  down  each  side  of  the  opening 
and  tied  in  jilace  by  the  catgut.  The  edges  of  the  incised  duct 
are  approximated  with  tissue  forceps,  and  covered  with  several 
thicknesses  of  a  third  layer  of  gauze,  and  a  rubber  tube  passed 
into  the  gauze  well  and  fastened  by  one  of  the  catgut  threads.  The 
gall-bladder  is  opened  and  drained  in  the  usual  manner,  to  pre- 
vent tension. 

Cholecystectomy  should  be  more  frequently  employed.  Hans 
Kehr  is  emphatic  on  this  point.  It  requires  a  larger  incision  and 
more  maniinilation,  and,  as  performed,  is  a  far  more  serious  opera- 
tion than  cholecystotomy.  It  is  often  necessary,  as  a  secondary 
operation  after  the  drainage  of  an  infected  gall-bladder,  or  after 
failure  of  cholecystotomy  to  cure  from  any  cause. 

Considering  that  the  mucous  membrane  is  the  only  part  of  the 
gall-bladder  which  gives  rise  to  after-trouble,  in  three  cases  during 
the  past  year  we  have  opened  the  gall-bladder  and  removed  the 
mucous  membrane  to  the  cystic  duct.  At  this  point  the  mucosa 
is  cut  across  part  at  a  time,  and  one  or  two  bleeding  points  caught 
with  forceps  and  tied,  the  duct  being  left  open. 

The  muscular  and  peritoneal  coats  are  sutured  into  the  incision 

and  drainage  established  in  the  usual  manner.     It  is  surprising  how 

easily  this  can  be  accomplished.     The  mucous  membrane  is  tough 

and  separates  from  the  muscular  coats  readily.     The  adhesions 

to  the  peritoneal  coat  are  separated  only  enough  to  explore  the 

ducts.     It  does  not  require  a  long  incision,  nor  does  it  necessitate 
VOL.  I — iS 


354  WILLIAM    J.    MAYO 

prolonged  manipulation,  and  yet  the  essential  part  has  been  re- 
moved to  the  same  extent  as  in  the  usual  cholecystectomy. 

This  modified  operation  adds  little  to  the  risks  of  an  ordinary 
cholecystotomy. 

[Note. — Since  writing  this  paper  the  author  has,  in  two  addi- 
tional cases,  performed  the  modified  cholecystectomy  as  detailed 
above.  In  one  of  these  cases  a  stone  impacted  in  the  cystic  duct 
was  removed  with  the  mucous  membrane  of  the  gall-bladder  and 
duct  to  a  point  beyond  the  stone  with  perfect  ease.] 


CHOLECYSTECTOMY,  WITH  ESPECIAL  REF- 
ERENCE TO  THE  REMOVAL  OF  THE 
MUCOUS  MEMBRANE  OF  THE  GALL- 
BLADDER   AS    A    SUBSTITUTE 

REPORT  OF  A  CASE  IN  WHICH  THE  GALL-BLADDER 
WAS  REMOVED  FOR  MALIGNANT  DISEASE* 

WILLIAM    J.    MAYO 


Excision  of  the  gall-bladder  is  clearly  indicated  in  four  groups  of 
cases:  (1)  For  traumatisms,  such  as  gun-shot  wounds  or  crushing 
injuries.  (2)  Phlegmonous  cholecystitis  and  gangrene  of  the  gall- 
bladder. (3)  For  malignant  disease.  In  these  three  groups  all 
the  coats  of  the  gall-bladder  are  involved  in  the  diseased  process, 
or  injury  and  complete  cholecystectomy  is  a  logical  sequence. 
(4)  For  the  relief  of  permanent  obstruction  of  the  cystic  duct,  the 
common  duct  being  patent.  In  this  last  group  only  the  mucous 
membrane  is  at  fault;  if  this  were  not  present,  there  would  be 
nothing  to  drain,  and  obliteration  of  the  cystic  duct  would  be 
harmless.  It  is  this  class  of  cases  in  which  removal  of  the  mucous 
membrane  of  the  gall-bladder  offers  a  quick  and  safe  method  of 
relief.  In  the  complete  operation  of  cholecystectomy  the  close 
relation  which  exists  between  the  gall-bladder  and  the  liver,  and 
the  deep  situation  of  the  pedicle  at  the  cystic  duct,  introduce 
certain  elements  of  danger  which  cannot  be  ignored,  and  which 
render  the  operation  in  every  way  more  serious  than  simple  re- 
moval of  the  mucous  membrane.  The  latter  procedure  adds  but 
little  to  the  risks  of  an  ordinary  cholecystotomy. 

*  Presented  to  the  Section  on  Surgery  and  Anatomy,  at  the  Fifty-first  Annual 
Meeting  of  the  American  Medical  Association,  held  at  Atlantic  City,  X.  J.,  June 
5-8,  1900.     Reprinted  from  "Jour.  Amer.  Med.  Assoc,"  December  1,  1900. 

855 


356  WILLIAM   J.    MAYO 

Traumatisms  to  the  gall-bladder  requiring  its  ablation  are  but 
rarely  met  with,  and  are  usually  associated  with  grave  injuries  to 
the  liver.  A  small  number  of  cases  have  been  reported,  which  not 
infrequently  were  the  result  of  indirect  violence.  In  the  one  case 
of  this  kind  which  I  treated  free  drainage  enabled  repair  of  the 
ruptured  gall-bladder  to  take  place  without  excision.  In  acute 
phlegmonous  cholecystitis  and  gangrene  of  the  gall-bladder  two 
courses  are  open:  (1)  Freely  to  drain  the  gall-bladder  and  pack  the 
surrounding  space  with  gauze,  or  (2)  to  remove  the  offending  organ 
at  once.  The  principles  are  essentially  the  same  as  in  the  treat- 
ment of  appendicular  abscesses  by  drainage,  leaving  the  appendix, 
or  to  remove  the  appendix,  if  possible,  at  the  primary  operation. 

In  three  instances  of  this  character  the  writer  has  excised  the 
gall-bladder  and  drained  freely,  the  bleeding  surface  of  the  attached 
liver  and  the  infected  stump  being  covered  with  gauze  held  firmly  in 
position  by  sutures  of  fine  catgut.  The  stitches  hold  the  gauze  in 
place  until  adhesions  form,  and  the  catgut  is  absorbed  before  re- 
moval of  the  drainage  is  indicated.  In  this  manner  sufficient  pres- 
sure can  be  obtained  to  check  the  oozing  and  limit  extravasation. 

The  gall-bladder,  with  adjacent  liver  substance,  has  been  re- 
moved on  a  number  of  occasions  for  malignant  disease  by  cutting 
instruments,  the  Paquelin  cautery,  or  by  the  elastic  ligature. 
A  case  of  like  nature  was  operated  upon  recently  by  the  author, 
and  on  account  of  its  rarity  is  reported  somewhat  in  detail  as 
follows : 

Mrs.  E.  R.,  American,  aged  sixty-five,  was  admitted  to  St. 
Mary's  Hospital  April  18,  1900. 

History. — She  has  been  in  her  usual  health  until  within  the 
past  six  months.  During  this  time  she  has  suffered  from  a  boring 
pain  in  the  right  side,  which  of  late  has  become  almost  constant. 
Gastric  symptoms  have  been  of  moderate  severity.  There  have 
been  some  loss  of  appetite  and  constipation,  with  a  decrease  of  15 
pounds  in  weight.  No  jaundice  nor  history  of  colics.  Examina- 
tion reveals  a  somewhat  movable  tumor  in  the  right  hypochondriac 
region,  evidently  connected  with  the  liver.  The  mass  has  a  nodu- 
lar feel. 

Exploratory  incision  April  21,   1900.     A  carcinomatous  gall- 


CIIOLECYSTKf  TO.MV  357 

bladder  involved  the  adjacent  portion  of  the  liver  and  the  cystic- 
duct.  There  was  some  infiltration  along  the  common  duct,  aiul 
extending  to-  the  duodenum  at  one  place  was  a  considcrahic  arc;i 
of  adhesions.  A  few  glands  in  the  angle  between  the  cystic  and 
hepatic  ducts  were  infected.  The  disease  was  so  definitely  cir- 
cumscribed with  such  slight  glandular  involvement  that  its  re- 
moval was  decided  upon.  The  excision  began  at  the  common  duc-t, 
two  inches  of  which  was  removed  with  one  inch  of  the  hcjjatic 
duct.  The  vessels  were  caught  and  tied  as  divided.  An  area  of 
adherent  duodenum  the  size  of  a  silver  dollar  was  included  in  the 
excision.  The  opening  in  the  intestine  was  closed  by  circular 
purse-string  sutures,  and  the  lower  end  being  thus  freed,  the  gall- 
bladder with  the  attached  liver  was  removed  with  the  Paquelin 
cautery  knife.  The  larger  vessels  were  grasped  with  forceps.  The 
free  venous  oozing  from  the  liver  substance  was  not  controlled  by 
the  cautery,  although  easily  checked  by  slight  pressure,  the  blood- 
current  having  but  little  force.  A  piece  of  sterile  gauze  the  size 
of  the  wrist  was  placed  in  the  cavity,  and  a  continuous  suture  of 
fine  catgut  was  run  through  the  liver  substance  on  each  side  of 
and  around  the  gauze,  effectively  compressing  the  bleeding  liver 
margins  against  it,  and  controlling  the  hemorrhage.  The  portal 
vein  was  exposed  to  a  considerable  extent  in  the  bottom  of  the 
cavity.  Adequate  drainage  was  afforded,  the  bile  being  conducted 
to  the  surface.  Recovery  was  uneventful.  The  gall-bladder 
contained  a  single  stone,  %  inch  in  diameter. 

The  fourth  class  of  cases  in  which  a  permanent  obstruction 
exists  in  the  cystic  duct  are  far  more  numerous.  The  obstruction 
may  be  the  result  of  adhesive  inflammation  in  the  outer  coats, 
causing  angulation  or  the  long  lodgment  of  a  stone  in  the  cystic 
duct,  with  resulting  ulceration  and  cicatrization,  or  stricture  from 
any  cause. 

Of  132  operations  on  the  gall-bladder  and  bile-ducts  which 
have  been  made  in  St.  Mary's  Hospital  during  the  past  nine  years, 
11  were  cholecystectomies  and  7  of  these  were  for  the  relief  of  ob- 
struction in  the  cystic  duct,  which  had  caused  mucous  fistulas  or 
recurrent  attacks  of  colic,  due  to  retention  of  the  secretions  in  the 
gall-bladder.  The  indication  in  these  cases  is  clear.  It  is  the 
continuous  secretion  from  the  mucous  membrane  prevented  by  the 
olistruction   from   draining  through  the  natural   channel,   which 


358  WILLIAM    J.    MAYO 

causes  the  trouble;  the  peritoneal  and  muscular  coats  are  harmless, 
and  by  removing  the  mucous  membrane  down  to  the  obstruction, 
relief  is  afforded.  In  my  own  experience,  obstruction  of  the  cystic 
duct  is  met  with  either  primarily — cystic  gall-bladder — or  occurs 
secondarily  after  operation  for  gall-stone  disease  in  about  10  per 
cent,  of  cases.  It  seems  unnecessary  to  say  anything  about  technic. 
The  mucous  membrane  of  the  gall-bladder  is  easily  detached,  and 
as  aU  the  adhesions  are  to  the  peritoneal  and  muscular  coats,  the 
separation  is  readily  effected.  The  gall-bladder  partly  inverts  it- 
self as  the  cystic  duct  is  approached,  rendering  easy  removal  of  an 
impacted  stone.  If  it  is  small  and  deeply  placed,  removal  of  the 
mucous  membrane  is  more  difficult,  but  can  be  accomplished  more 
readily  than  complete  extirpation.  One  or  two  small  vessels  re- 
quire ligation.  The  muscular  and  peritoneal  coats  are  sutured  to 
the  upper  angle  of  the  wound  in  the  abdominal  wall,  and  drainage 
established  as  in  ordinary  cholecystotomy.  As  a  secondary  opera- 
tion, removal  of  the  mucous  membrane  is  most  serviceable.  Drain- 
age has  failed  to  cure,  and  the  adhesions  formed  by  the  previous 
union  of  gall-bladder  to  the  external  incision  vastly  increases  the 
difficulty  of  complete  extirpation.  The  operation  in  these  cases 
is  best  accomphshed  as  follows: 

An  incision  is  made  into  the  abdominal  cavity  on  the  inner — 
median — side  of  the  site  of  the  former  operation,  but  these  external 
attachments  of  the  gall-bladder  are  not  severed.  The  adhesions 
are  separated  to  a  limited  extent  on  the  inner  side,  to  enable  careful 
exploration  of  the  ducts.  The  adhesions  in  other  directions  are 
purposely  left,  and  act  as  a  protection  to  the  outer  and  lower  por- 
tion of  the  operative  field.  After  proper  gauze  protection  the  gall- 
bladder is  opened  on  the  inner  side  in  the  explored  area,  about  13^ 
inches  down,  and  this  incision  is  carried  outward  toward  the  ex- 
ternal attachments.  The  separation  of  the  mucous  membrane  is 
begun  at  the  middle,  and  the  enucleation  carried  down  to  the  cystic 
duct,  where  it  is  di\aded  at  the  point  of  obstruction.  The  separa- 
tion is  then  proceeded  with  from  T\'ithin  outward  until  completed. 
The  scar  tissue  at  the  place  where  the  gall-bladder  is  attached  to 
the  abdominal  wall  renders  detachment  difficult  if  commenced  at 


f'HOLECYSTKC  T(JM  Y  359 

that  point,  but  by  Ix'^inning  well  })(>l()\v,  tlio  muroiis  mfinbrane 
can  be  readily  sejjarated. 

The  muscular  and  peritoneal  coats  are  drained  in  the  usual 
manner,  a  {)iece  of  sterile  gauze  being  tacked  about  the  inner 
divided  wall  by  a  few  catgut  sutures,  which  renders  the  drainage 
quite  i)erfect. 


THE  SURGICAL  SIGNIFICANCE  OF  JAUNDICE* 

WILLIAM    J.    MAYO 


Jaundice  as  a  result  of  diseased  states  of  the  blood  has  been 
eliminated  as  irrelevant  to  this  discussion,  and  reference  will  be 
made  only  to  those  forms  of  icterus  due  to  an  impediment  to  the 
outflow  of  bUe  through  the  liver-ducts.  Obstruction  to  the  in- 
testinal dehvery  of  the  bile  is  caused,  first,  by  swelKng  of  the  mu- 
cous lining  of  the  ducts,  due  to  an  infection;  second,  by  gall-stones 
in  the  common  duct;  third,  by  disease  or  tumors  involving  the 
ducts;  fourth,  by  disease  or  tumor  of  the  head  of  the  pancreas. 
Pressure  from  without  the  ducts,  as  in  certain  mahgnant  growths 
of  the  pylorus,  may  also  interfere  directly  with  the  biliary  flow; 
and,  again,  some  forms  of  cirrhosis,  either  of  the  atrophic  or  of 
the  hypertrophic  variety,  may  obstruct  the  smaller  liver-ducts, 
cutting  off  from  the  main  channel  the  secretion  of  the  part,  and 
result  in  jaundice.  In  one  way  or  the  other  the  common  forms  of 
jaundice  are  due  to  mechanical  interference,  and  by  careful  at- 
tention to  the  history,  with  the  physical  examination,  a  differential 
diagnosis  may  be  made;  if  not  pathologic,  at  least  a  surgical, 
diagnosis  may  be  made;  that  is  to  say,  a  condition  which  can  be 
relieved  surgically,  although  it  may  be  any  one  of  several  forms 
of  disease. 

Gall-stones  in  the  gall-bladder  do  not  produce  jailndice  except 
under  rare  circumstances.  The  rule  is  that  jaundice  with  gall- 
stones means  a  stone  in  the  common  duct.  The  exceptions  are, 
first,  an  infection  of  the  gall-bladder  which  travels  along  the  ducts, 
producing  a  cholangitis,  usually  accompanied  by  some  inflamma- 
tory reaction,  slight  temperature,  a  quickened  pulse,  and  follows 
an  attack  of  colic,  with  or  without  the  passage  of  a  calculus;  second, 

*  Reprinted  from  "Northwestern  Lancet,"  January  1,  1902. 
360 


TIIK    srH<;i(AL    SHiMl'ICANCK    OF   JAINDICIO  .'}(>  I 

an  inflamed  gall-bladder  (cholecystitis),  in  which  infection  lias 
passed  throu<fh  the  coats,  and  a  local  peritonitis  results,  which 
acts  mecha/iically  upon  the  l)ile-i)assages.  The  jaundice  in  these 
cases  is  not  complete,  and,  as  a  rule,  quickly  subsides. 

I  cannot  too  strongly  emphasize  the  fact  that  jaundice  is  not 
to  be  expected  from  uncomplicated  gall-stone  disease.  It  is 
altogether  a  secondary  phenomenon. 

Stones  in  the  common  duct  produce  a  jaundice  which  at  first  is 
incomplete.  In  the  early  stages  the  duct  dilates,  and  when  the 
biliary  accunnilation  is  under  some  pressure,  the  bile  passes  the 
obstruction  with  colicky  pains,  and  the  icterus  clears  up  somewhat. 
This  may  happen  several  times  a  day.  If  the  stone  be  of  sufficient 
size  materially  to  obstruct  the  passage,  the  intermittent  jaundice 
takes  on  a  remittent  form;  that  is,  it  never  entirely  clears  up.  In 
time  the  duct-wall  becomes  infiltrated  with  connective-tissue  cells, 
contracts  tightly  about  the  stone,  and  the  jaundice  becomes  com- 
plete. 

Stones  which  pass  the  cystic  duct  usually  pass  through  the 
common  duct  easily,  as  the  latter  is  three  times  the  size  of  the 
former. 

Stones  which  remain  in  the  main  biliary  passage  are  therefore 
either  of  large  size,  and  have  been  slowly  forced  into  the  duct,  or 
are  the  so-called  "ball-valve"  stone  of  Fenger.  In  the  latter  case 
the  papilla  of  the  common  duct  on  the  surface  of  the  intestine  is  a 
little  smaller  than  the  stone  and  the  stone  rolls  about  in  the  duct. 
At  times  it  is  at  the  intestinal  orifice,  causing  a  sHght  colic  and 
increase  in  jaundice,  then  rolling  away,  with  subjective  relief. 
Such  rolling  stones  are  usually  accompanied  by  an  infection  of  the 
bile-passages,  and  chills,  slight  in  character,  fever,  and  sweats  are 
frequent  accompaniments. 

Many  of  these  patients  come  to  us  with  a  diagnosis  of  relapsing 
biliary  fever  or  malaria.  It  is  to  be  noted  that  the  jaundice  is 
incomplete  and  of  varying  intensity.  Occasionally,  the  stone 
gains  in  size  by  additions  from  the  infected  ducts  and  biliary  de- 
posits, forming  a  large,  soft  stone,  having  as  its  nucleus  the  original 
stone  from  the  gall-bladder.  Stones  in  the  common  duct  cause 
more  or  loss  j;um(li(«> — soinelimes  very  little. 


362  WILLIAM   J,    MAYO 

We  have  several  times  removed  stones  from  the  common  duct, 
or  a  diverticulum  of  it,  in  which  jaundice  was  not  present. 

Jaundice  from  gall-stones  should  give  a  history  of  previous 
colics.  The  physical  examination  will  usually  be. negative.  Con- 
trary to  the  prevalent  opinion,  the  gall-bladder  is  shrunken  in- 
stead of  distended,  in  the  majority  of  cases.  Occasionally  it 
happens  that  the  gall-bladder  will  be  found  distended.  In  such 
cases  it  will  probably  also  contain  stones.  The  reason  for  the 
shrunken  condition  of  the  gall-bladder  lies  in  the  great  inflamma- 
tory thickening  of  its  coats  and  the  contraction  of  this  connective 
tissue  after  the  stone  is  expelled. 

Jaundice  from  malignant  disease  may  have  a  history  of  gall- 
stone attacks  years  before,  and  the  cancer  is  often  due  to  the  irrita- 
tion of  the  calculi.  The  jaundice  comes  on  after  some  indefinite 
history  of  abdominal  disease,  and  is  preceded  by  loss  of  flesh  and 
progressive  weakness,  without  much  acute  pain.  The  jaundice 
slowly  but  steadily  increases,  and  does  not  change  day  by  day  in 
intensity,  excepting  to  get  deeper.  On  palpation  the  distended 
gall-bladder  can  often  be  felt.  This  enlargement  is  usually  the 
rounded  end  of  the  gall-bladder,  occasionally  nodular,  due  to  an 
extension  of  the  malignant  process.  In  the  latter  stages  a  little 
ascitic  fluid  can  be  detected  in  the  abdomen.  The  age  of  the 
patient  over  thirty -flve  is  to  be  noted. 

Chronic  inflammation  of  the  pancreas  is  accompanied  by  jaun- 
dice in  many  cases,  and  is  often  confounded  with  malignant  disease. 
The  previous  history  may  be  that  of  gall-stones  or  obscure  epi- 
gastric distress. '  The  jaundice  does  not  change  in  the  early  stages, 
as  is  to  be  expected  in  a  gall-stone  in  the  common  duct,  and  there 
are  fewer  of  the  repeated  colicky  pains.  It  also  differs  from  malig- 
nant disease  in  the  fair  degree  of  health  maintained  for  a  length  of 
time  beyond  the  expectancy  of  cancer.  The  gall-bladder  can  be 
felt  distended,  but  without  nodules,  and  the  patient  may  be  of  any 
age. 

The  hypertrophic  cirrhosis  of  the  liver  of  Hanot  is  a  disease  of 
young  adults,  and  the  jaundice  is  slight,  but  persistent.  The  great 
size  of  the  liver  makes  the  diagnosis. 

Atrophic  cirrhosis  and  allied  forms  of  hypertrophic  cirrhosis  are 


THE    SLH(;KAL   significance    of   JAtSDICE  363 

usually  found  in  adults.  Tlio  jaundice,  if  i>n'S(>nt,  is  a  late  symp- 
tom, and  ascites  is  frequent.  Here,  again,  physical  examination 
of  the  liver  and  spleen,  with  the  alcoholic  history,  comi)letes  the 
tliagnosis. 

To  recapitulate:  First,  jaundice  is  not  to  he  expected  in  un- 
comi)licate(l  gall-stone  disease. 

Second,  jaundice  from  a  stone  obstructing  the  common  duct 
gives  the  history  of  previous  attacks  of  gall-stone  colic,  varies 
greatly  in  intensity  in  the  early  stage,  and  these  changes  are  ac- 
companied by  colicky  pains.  An  early  history  can  usually  be 
obtained  of  some  little  fever,  and  at  times  chilly  .sensations  or 
sweats.     The  gall-bladder  cannot  often  be  palpated. 

Third,  in  malignant  di.sease  the  loss  of  flesh  before  jaundice, 
the  age  of  the  patient,  and  the  unchanging  (except  for  the  worse)  of 
the  icteric  hue,  with  a  distended  and,  perhaps,  nodular  gall-bladder 
or  adjacent  tumor,  completes  the  clinical  picture. 

Fourth,  jaundice  from  chronic  pancreatitis  will  probably  be 
confused  with  malignant  disease.  The  po.ssibility  of  its  existence 
leads  to  an  examination  as  to  the  history,  the  age  of  the  patient, 
and  the  duration  of  the  symptoms. 

Fifth,  the  various  forms  of  cirrhosis  accompanied  by  jaundice 
are  to  be  distinguished  by  the  physical  examination  of  the  liver 
and,  occasionally,  the  size  of  the  spleen. 

Catarrhal  jaundice,  with  which  every  practitioner  is  familiar, 
has  not  been  mentioned.  It  is  a  disease  most  common  in  young 
adults,  and  is  usually  due  to  an  extension  of  a  mild  infection  from 
the  gastro-intestinal  tract.  It  is  sometimes  seen  in  an  epidemic 
form.  The  age  of  the  patient,  the  slow  pulse,  and  the  lack  of 
general  symptoms  and  short  duration  make  the  differentiation  easy. 

Catarrhal  jaundice  may,  in  isolated  cases,  complicate  appendi- 
citis, pneumonia,  cancer  of  the  stomach,  and  a  host  of  common 
diseases;  but  as  in  these  cases  it  is  usually  incomplete  and  tran- 
sient, it  does  not  long  mask  the  primary  source  of  disease.  How- 
ever, these  secondary  conditions  are  at  times  most  serious,  the 
catarrhal  infection  developing  a  purulent  cholangitis,  and  death 
resulting  from  multiple  abscess  of  the  liver,  with  the  usual  symp- 
toms of  sepsis,  accompanied  by  a  marked  jaundice. 


CANCER  OF  THE  COMMON  BILE-DUCT.    RE- 
PORT OF  A  CASE  OF  CARCINOMA  OF 
THE   DUODENAL   END   OF  THE 
COMMON  DUCT  WITH  SUC- 
CESSFUL  EXCISION* 

WILLIAM   J.    MAYO 


Primarj^  carcinoma  of  the  common  duct  is  rare.  In  4578 
autopsies  Kelynack  found  8  cases  of  primary  cancer  of  the  gall- 
bladder, and  but  2  having  origin  in  the  duct.  Musser  collected  100 
cases  of  carcinoma  of  the  gall-bladder  and  18  of  the  bile-ducts. 
The  site  of  the  neoplasm  in  the  common  duct  is  usually  either  at 
the  juncture  of  the  hepatic  and  cystic  ducts  or  near  its  duodenal 
termination.  The  18  cases  collected  by  Musser  showed  3  in 
the  hepatic  duct,  1  at  the  juncture  of  the  cystic  and  hepatic 
duct,  and  14  in  the  common  duct,  and  of  these  latter,  9  were  at 
or  near  the  papilla.  In  17  cases  of  cancer  of  the  ducts  Rolleston 
found  15  in  the  common  duct,  and  of  these  10  at  or  near  the  papilla. 

As  to  the  etiology  of  carcinoma  of  the  common  duct,  there  is 
some  question.  It  is  conceded  that  gall-stones  are  the  most  com- 
mon cause  of  cancer  of  the  gall-bladder.  In  Musser 's  100  cases  of 
gall-bladder  carcinoma  69  contained  gall-stones,  and  he  found  evi- 
dence that  calculi  had  at  one  time  been  present  in  the  majority  of 
the  remainder.  Primary  cancer  of  the  gall-bladder  and  gall-stone 
disease  are  more  common  in  females  than  in  males,  and  in  about  the 
same  proportion.  In  22  collected  cases  of  cancer  at  or  near  the 
papilla  of  the  common  duct  Edes  found  gall-stones  in  but  4,  and 
3  of  these  in  the  gall-bladder.  In  36  cases  of  cancer  of  the  common 
duct  Rolleston   found  gall-stones  in  less  than   half.      Cancer  of 

*  Reprinted  from  "The  St.  Paul  Medical  Journal,"  June,  1901. 
364 


CANCKU  or  Tin;  (om.mo.n   iiiij;-i)i  (T  3fi/> 

the  common  diicl  is  ('(jiially  frccjiicnl  in  the  male  and  female,  which 
does  not  favor  the  belief  that  gall-stones  are  the  cause  of  the  ma- 
lignant process  in  the  duct,  although  calculi  an-  und(>ul)l((lly  an 
important  ctiologic  factor  in  cancer  of  the  gall-bladder.  The  ex- 
tensive exi)erience  of  Mayo  Robson,  however,  entitles  his  opinion 
to  great  weight,  and  he  states  his  belief  that  gall-stones  arc  the 
most  common  cause  of  the  malignant  neoplasms  in  the  biliary  pas- 
sages, although  the  calculi  have  not  remained  in  situ. 

The  histologic  variety  of  carcinoma  of  the  ducts  is  always  of 
the  columnar  cell  type,  although  Robson  states  that  secondary 
degeneration  of  papillomata  occurs.  Systemic  infection  is  rare; 
the  growth  usually  progresses  by  contiguity,  and  sooner  or  later 
the  lymph-glands  of  the  gastrohepatic  omentum  are  involved.  In 
some  of  the  cases  reported  the  growth  was  very  small  at  autopsy, 
even  after  a  year  or  more  of  marked  symptoms,  notably  the  cases 
reported  by  Edes,  in  which  it  was  not  larger  than  a  bean.  Death 
usually  occurs  from  debility,  the  result  of  the  jaundice  and  in- 
fection of  the  biliary  ducts.  The  symptoms  are  not  distinctive, 
and  the  diagnosis  cannot  often  be  made.  The  chronic  jaundice 
and  cachexia  are  not  dissimilar  to  malignant  growths  of  the  head 
of  the  pancreas,  and  the  occurrence  of  glycosuria  and  fatty  stools 
is  not  sufficiently  common  in  the  latter  disease  to  aid  frequently 
in  differentiation. 

In  primary  carcinoma  of  the  common  duct  pain  is  not  usually 
severe,  in  this  respect  differing  from  stones  in  the  same  situation, 
but  as  so  many  cases  have  or  at  one  time  had  stones,  the  diagnostic 
importance  of  the  pain  symptom  is  not  great.  There  is  usually  no 
tumor  present,  a  sign  commonly  existing  in  cancer  of  the  gall-blad- 
der. An  exploration  of  the  ducts  in  doubtful  cases  is  the  only  way 
a  positive  diagnosis  can  be  established. 

McBurncy  first  called  attention  to  the  case  with  which  the 
duodenum  can  be  opened  for  the  purpose  of  removing  stones  im- 
pacted in  the  diverticulum  of  Vater,  and  first  performed  the  oper- 
ation. We  have  several  times  successfully  opened  the  duodenum 
for  this  purpose,  and  a  large  number  of  such  operations  are  now  on 
record.     Carle,  in  an  address  before  the  Italian  Surgical  Congress, 


366  WILLIAM   J.    MAYO 

strongly  urges  incision  of  the  duodenum  for  removal  of  stones  or 
growths  from  the  duodenal  end  of  the  common  duct,  and  cites  cases 
in  which  stones  were  formed  in  the  duct  and  might  later  give  rise 
to  carcinoma.  Cancer  higher  up  in  the  duct  would  necessitate 
union  between  the  remaining  fragment  of  the  duct  and  the  duo- 
denum, as  Halsted  succeeded  in  doing.  As  a  palliation  chole- 
cystenterostomy  is  the  indicated  procedure.  The  anastomosis 
may  be  made  either  between  the  gall-bladder  and  duodenum,  or, 
if  the  latter  is  involved,  with  the  transverse  colon  or  jejunum. 
We  have  three  times  joined  the  gall-bladder  to  the  transverse 
colon  for  inoperable  obstruction  of  the  common  duct,  and  these 
cases  did  fully  as  well  in  every  respect  as  three  cases  in  which  the 
duodenum  was  used  as  a  receptacle  for  the  biliary  discharge.  One 
case  supposed  to  be  malignant  proved  not  to  be  so  by  living  in  good 
health  six  years  after  uniting  the  gall-bladder  and  colon.  As  a 
result  of  our  own  experience  I  see  no  reason  why  the  transverse 
colon  may  not  serve  as  well  as  the  duodenum,  provided  the  latter, 
more  favorable,  situation  is  not  practicable.  The  proximity  of 
the  large  bowel  and  the  nature  of  its  coats  render  anastomosis 
with  the  gall-bladder  easy,  and  in  palliation  of  malignant  disease 
it  is  perhaps  almost  as  good,  for  the  purpose,  as  the  duodenum. 
In  the  original  work  of  Winiwarter  it  was  the  chosen  method.  A 
few  cases  of  enormous  distention  of  the  common  duct  have  been 
reported.  Robson  details  an  instance  in  which  he  had  been  able 
to  suture  such  a  cystic  formation  to  the  surface  of  the  body. 
Summers,  in  a  most  interesting  case,  united  the  common  duct  to 
the  duodenum  with  a  successful  result.  In  these  cases  the  ob- 
struction was,  however,  non-malignant. 

The  following  case  came  under  my  observation: 

M.  K.,  female,  age  fifty-nine,  German.  Admitted  to  St. 
Mary's  Hospital  November  1,  1900. 

History. — For  many  years  patient  has  suffered  from  sudden 
attacks  of  pain  arising  in  the  epigastric  and  extending  to  the  right 
hypochondriac  region.  The  suffering  has  been  very  severe,  lasting 
from  two  to  six  hours,  and  ending  with  an  attack  of  vomiting 
accompanied  by  prostration.     At  times  has  been  somewhat  jaun- 


CANCEIl    OF   THK    COMMON    H1M;-I)I  (T  367 

diced  alter  lliese  at  lacks.  Ahoiil  one  year  a^o  appelit*-  liegaii  to 
fail,  distress  in  the  stoiiiacli  Ix-caine  more  constant,  but  less  severe, 
and  there  has  been  a  j)ro^ressi\e  loss  of  weight — over  40  poninls 
in  all.     Family  and  personal  history  j^ood. 

J'Lvaniindlion.  I'atient  somewhat  emaciated;  there  is  a  marked 
cachexia  with  a  moderate  jaundice.  l*ulse,  temperature,  and 
respiration  normal.  Liver  can  be  outlined  just  below  the  free 
margin  of  ribs;  gall-bladder  cannot  be  felt.  There  is  a  tenderness 
and  some  rigidity  of  the  muscles  in  this  region,  otherwise  examina- 
tion negative.  Urine  has  a  trace  of  albumin  and  nuicli  bile. 
Test-meal  developed  free  hydrochloric  acid,  and  on  distention 
with  air  the  outlines  of  the  stomach  were  normal.  Stools  con- 
tained traces  of  bile,  })ut  were  light  colored.  The  history  was  clear 
as  to  tiie  presence  of  gall-stones,  but  the  patient  had  a  distinct 
malignant  cachexia. 

Diagnosis. — Either  gall-stones  in  the  common  duct  or  malig- 
nant disease. 

Xovcmber  ■kl:  Incision  through  the  right  rectus  muscle.  Liver 
somewhat  larger  than  normal;  gall-bladder  enlarged,  containing 
bile  mixed  with  ropy  mucus,  and  a  single  non-faceted,  dark-colored 
gall-stone,  the  size  and  shape  of  a  small  pea.  The  cystic  and  com- 
mon ducts  were  moderately  dilated,  but  no  stone  nor  other  ob- 
struction could  be  detected  on  most  careful  exploration.  Gall- 
bladder drained  to  the  surface  after  attaching  to  the  parietal  peri- 
toneum. The  findings  at  the  operation  were  unsatisfactory,  and 
did  not  account  for  the  condition  of  the  patient.  For  forty-eight 
hours  drainage  of  bile  was  free,  but  gradually  increased  in  quantity 
up  to  two  or  more  pints  a  day;  the  skin  became  greatly  irritated 
from  the  discharge,  and  examination  showed  that  a  large  part,  if 
not  all,  of  the  pancreatic  secretion  was  being  discharged,  with  all 
the  bile,  to  the  surface.  Stools  contained  no  bile.  A  Jacol)'s 
self-retaining  female  catheter  was  inserted  into  the  gall-blad- 
der through  the  fistulous  opening,  and  in  this  way  the  drainage 
was  directed  into  a  receptacle  without  contact  with  the  skin.  It 
was  evident  that  there  was  an  obstruction  which  had  been  over- 
looked at  the  duodenal  extremity  of  tiie  duct. 

Patient  was  in  a  very  feeble  condition,  and  on  November  30th 
was  allowed  to  return  home.  Even  with  the  continuous  drainage 
she  improved  somewhat.  The  jaundice  disappeared,  and  on 
January  29,  1901,  she  was  readmitted  to  the  hospital.  On  Jan- 
uary 31,  1901,  an  incision  four  inches  in  length  was  made  to  the 
inner  side  of  the  fistula.  The  adhesions  were  separated,  and  the 
common  duct  and  duodenum  thoroughly  exposed.     At  the  ex- 


368  WILLIAM   J.    MAYO 

treme  end  of  the  common  duct  a  hard  body  could  be  felt  through 
the  wall  of  the  duodenum,  the  size  of  a  filbert,  which  was  supposed 
to  be  a  stone  lodged  in  the  ampulla  of  Vater.  An  incision  was  made 
two  inches  in  length  in  the  anterior  wall  of  the  duodenum,  exposing 
a  grayish- white  mass  which  was  strictly  localized  to  the  site  of  the 
papilla  of  the  common  duct.  Its  size  did  not  exceed  the  end  pha- 
lanx of  the  forefinger.  About  one-third  of  its  length  projected  into 
the  free  lumen  of  the  duodenum,  and  two-thirds  posterior  to  the 
intestinal  wall.  The  tumor  was  excised,  exposing  the  free  end 
of  the  common  duct.  The  removal  was  made  partly  with  a  knife 
and  partly  "^dth  the  Paquelin  cautery,  and  finally  the  whole  raw 
surface  was  seared  with  the  cautery.  The  common  duct  was 
otherwise  free  of  obstruction.  The  incision  in  the  duodenum  was 
sutured.  No  enlarged  lymphatics  were  discovered,  and  no  secon- 
dary nodules  in  the  liver  or  pancreas  could  be  detected.  A  small 
drainage  wick  was  inserted  and  the  wound  closed.  The  attach- 
ment of  the  gall-bladder  to  the  skin  was  left  undisturbed.  The 
discharge  from  the  fistula  rapidly  diminished,  and  in  three  weeks 
had  completely  ceased.  Stools  became  normal  in  color,  and  the 
gain  in  the  weight  and  general  appearance  was  most  rapid.  The 
specimen  was  sent  to  LeCount  for  examination,  and  his  report  is 
as  follows: 

"Sections  cut  from  all  pieces  sent  after  parafiin  embedding 
were  stained  from  varying  levels.  The  tissue  is  from  the  duodenal 
wall,  and  some  sections  show  portions  of  Brunner's  glands.  The 
Lieberklihn's  glands  may  be  traced  to  lower  depths  than  normal 
through  a  very  inflammatory  mucosa  that  contains  a  few  small 
lymph-nodes  and  small  areas  of  hemorrhage.  Certain  of  these 
glands  are  directly  continuous  with  groups  of  epithelial  cells  that 
lie  deeply  ^dthin  the  mucosa  and  the  muscular  coats.  The  epi- 
thelium in  these  invasions  are  altered  as  follows :  They  lose  their 
columnar  shape,  become  possessed  of  larger  and  more  deeply 
stained  nuclei,  possess  karyokinetic  nuclei  in  many  instances,  and 
do  not  retain  their  characteristic  grouping,  being,  instead,  arranged 
in  disorderly  clumps  and  bunches  that  vary  in  size;  these  deeply 
lying  collections  of  epithelial  cells  always  possess  an  irregular  cavity 
that  simulates  a  gland  of  the  simple  tubular  type  or  a  gland-duct." 

One  may  conclude  from  this  that  not  only  is  the  tissue  from  a 
cylindrocellular  carcinoma,  but  that  the  structure  is  such  that  it 
strongly  supports  the  contention  of  Lohmer  ("Ziegler's  Beitrage," 
1900,  xxviii,  372),  who  asserts,  in  opposition  to  the  views  of 
Ribbert,  that,  in  glandular  carcinoma,  the  new  glands  are  produced 
by  a  direct  proliferation  of  preexisting  glands. 


CANCER   OF   THE    COMMON'    RILE-fJUCT  369 

So  far  as  the  writer  can  ascertain,  the  only  case  in  wliich  a  car- 
cinoma of  the  common  duct  has  l)een  excised  previously  to  the  one 
which  forms  the  basis  of  this  communication  was  that  of  Wm.  S. 
Ilalsted.  Tliis  case  being  the  first  of  its  kind  on  record,  and 
extremely  interest iiig,  I  c|uote.  with  his  consent,  from  the  "Boston 
Medical  and  Surgical  Journal,"  vol.  cxli,  December  '28,  1899,  No. 
26,  645: 

"Primary  Carcinoma  of  the  Duodenal  Papilla  and  Diverticulum 
of  Voter,  Succesfifully  Removed  by  Operation;  Cystico-enterostomy 
Three  Months  After  the  First  Operation. — Mrs.  M.  L.,  aged  sixty. 
Until  August,  1897,  patient  was  well.  Her  first  symjjtom  was 
itching  of  the  skin,  which  came  on  suddenly  and  soon  became  se- 
vere. Patient  says  jaundice  did  not  appear  for  nearly  a  month 
after  the  onset  of  the  itching.  Before  the  appearance  of  jaundice 
diarrhea  set  in,  and  there  were  six  or  seven  stools  a  day,  which 
were  watery  and  clay-colored.  Patient  has  had  no  chills,  no  fever, 
and  no  sweating.  With  the  onset  of  the  jaundice  she  noticed 
shortness  of  breath  and  an  occasional  swelling  of  the  feet  and  legs. 
About  the  first  of  January,  1898,  she  had  persistent  bleeding  of  the 
gums  for  three  days,  following  the  extraction  of  a  tooth.  At  times 
the  hemorrhage  was  profuse.  Two  months  ago  a  tumor  was 
noticed  in  the  region  of  the  gall-bladder.  This  tumor  does  not 
seem  to  the  patient  to  have  increased  in  size,  and  has  never  been 
tender.  In  March,  1897,  she  had  several  attacks  of  severe  pain 
in  the  epigastrium.  These  attacks  were  not  accompanied  by 
vomiting,  fever,  or  sweating.  A  few  weeks  later  she  had  a  second 
but  milder  attack.  The  stools  were  light  in  color  for  two  or  three 
days  at  the  beginning  of  these  attacks,  but  patient  recalls  no  change 
in  the  color  of  the  urine  or  the  skin  at  that  time.  The  daughter 
of  the  patient  states  that  these  attacks  of  pain  were  very  severe, 
and  that  her  mother  seemed  very  ill. 

"Examination  February  1.'^,  1S9S. — Patient  somewhat  emaciated, 
but  fairly  well  nourished.  Mucous  membranes  pale.  Heart  and 
lungs  normal.  There  is  a  distinct  prominence  on  the  right  side, 
the  highest  point  of  which  is  midway  between  the  umbilicus  and 
anterior  superior  spine.  The  prominence  descends  markedly  with 
inspiration.  On  palpation,  the  prominent  area  proves  to  be  pear- 
shaped  and  distinctly  fluctuating.  The  border  of  the  liver,  wliich 
reaches  almost  to  the  crest  of  the  ilium,  can  be  distinctly  felt. 

"February   IJf,    1S9S,    Operation. — Vertical    incision    through 

rectus  muscle.     A  greatly  dilated  but  not  especially  dense  gall- 
voL.  I — 24 


370  WILLIAM   J.   MAYO 

bladder  presented  no  adhesions.  Liver  projects  5  cm.  below  costal 
margin.  Four  silk  sutures  placed  in  fundus  of  gall-bladder  with 
French  needles.  Small  aspirator  introduced  in  center,  between  su- 
tures; syringeful  of  clear  fluid  mthdrawn.  Gall-bladder  opened; 
contents  evacuated.  In  the  latter  part  of  the  fluid  were  many  fine, 
sand-like,  hard,  greenish,  round  particles,  suggesting  miniature 
gall-stones.  Common  and  cystic  ducts  were  dilated  to  the  size  of 
one's  thumb.  A  longitudinal  opening,  2  cm.  long,  was  made  in 
the  common  duct.  The  same  colorless  fluid  escaped  from  this  in- 
cision. Duct  explored  with  probe  and  finger.  What  seems  to  be 
a  small,  very  hard  stone,  is  felt  at  site  of  ampulla.  To  determine 
the  nature  of  this  body  an  incision  was  made  through  the  wall  of 
the  duodenum.  No  glandular  metastases  discoverable.  The 
stone-like  body  proved  to  be,  as  was  feared,  a  carcinoma  of  the 
papilla. 

"Excision  of  the  Cancerous  Growth. — To  give  the  growth  a  wide 
margin,  a  large  piece  of  duodenum  was  excised,  a  wedge-shaped 
piece  with  the  apex  at  the  mesenteric  border  of  the  intestine. 
About  three-quarters  of  an  inch  of  the  common  duct  and  a  shorter 
piece  of  the  pancreatic  duct  were  excised.  The  wound  in  the  duo- 
denum was  closed  in  the  usual  way  with  mattress  sutures.  This 
was  practically  an  end-to-end  anastomosis  of  the  duodenum.  The 
common  duct  and  pancreatic  duct  were  transplanted  into  the  duo- 
denum along  the  line  of  suture.  A  linear  incision  into  the  com- 
mon duct,  which  had  been  made  for  diagnostic  purposes,  was 
closed  over  a  hammer.  The  gall-bladder  was  sutured  to  the  peri- 
toneum. 

"Abdominal  wound  closed  in  the  usual  way:  the  peritoneum, 
with  a  running  silk  suture;  the  muscles  and  fascia,  with  buried 
silver  sutures,  and  the  skin,  with  a  continuous  subcuticular  silver 
suture.  Bismuth  gauze  inserted  to  protect  the  suture  of  the  in- 
testine and  common  duct.  Drainage-tube  surrounded  by  bis- 
muth gauze,  and  gutta-percha  tissue  inserted  into  gall-bladder  and 
held  in  place  by  a  purse-string  suture  of  catgut.  Wound  dressed 
with  silver-foil.  Gutta-percha  tissue  placed  between  the  raw 
edges  of  the  skin  and  the  gauze  packing.  Operation  lasted  three 
hours  and  ten  minutes.  Patient  experienced  apparently  no  shock 
from  the  operation, 

"May  5th,  Second  Operation. — Cholecystoduodenostomy  or 
cysticoduodenostomy.  Suture  of  fundus  of  gall-bladder.  Com- 
plete closure  of  abdominal  wound  except  for  drainage.  Incision 
alongside  of  old  cicatrix,  circumscribing  fistula.  Gall-bladder 
quite  small — no  larger  than  one's  thumb.     Liver  about  normal 


CANCER   OF   THE    COMMON   BILE-DUCT  371 

in  size.  Many  fine  adhesions  about  gall-bladder,  which  were 
easily  separated.  Gall-bladder  and  ducts  thoroughly  exposed. 
The  line  of  suture  of  common  duct  at  previous  operation  was 
readily  distinguishable  by  black  silk  stitches,  bvit  it  was  almost 
impossible  to  find  any  trace  of  the  duodenal  suture.  Common 
duct  incised  at  site  of  old  suture.  Probe  cannot  be  passed  into 
the  duodenum,  but  there  is  no  positive  evidence  of  the  recurrence 
of  the  cancer.  Unsuccessful  attempts  had  been  made  before  the 
operation  to  pass  a  probe  from  the  gall-bladder  through  the  com- 
mon duct  into  the  duodenum.  Opening  into  the  common  duct 
closed  in  the  usual  way  with  mattress  sutures  over  hammer.  An 
anastomosis  between  duodenum  and  the  gall-bladder  or  cystic 
duct  was  effected  without  much  difficulty,  although  the  parts  to 
be  sutured  were  very  deeply  situated  and  inaccessible.  The  duo- 
denum was  probably  a  little  less  freely  movable  than  at  the  pre- 
vious operation,  and  the  gall-bladder  was  so  much  reduced  in  size 
that  we  were  compelled  to  pass  some  of  the  stitches  into  what 
seemed  to  be  the  cystic  duct;  in  any  event,  the  neck  of  the  gall- 
bladder had  to  be  used  for  the  anastomosis.  A  bougie  a  boule 
passed  into  the  gall-bladder  was  used  as  a  darning-ball  to  assist 
in  the  placing  of  the  sutures.  All  the  sutures  were  passed  (none 
of  them  tied)  before  the  openings  into  the  neck  of  the  gall-bladder 
and  duodenum  were  made,  the  method  employed  being  that  which 
I  described  some  years  ago  for  intestinal  anastomosis.  The  open- 
ing in  the  fundus  of  the  gall-bladder  was  closed  except  for  protec- 
tive wicks,  wdiich  were  passed  through  this  fine  of  suture  into  the 
gall-bladder.  What  seemed  to  be  an  enlarged  gland  was  palpated 
during  the  operation,  but  not  removed.  Patient  suffered  little 
or  no  shock  from  the  operation.  In  the  early  autumn  of  1898  this 
patient  returned  to  the  hospital  too  ill  for  operative  interference, 
and  in  a  few  weeks  died.  During  the  summer  I  had  corresponded 
with  her,  urging  her  to  return  to  the  hospital,  for  it  was  clear  from 
her  letters  that  the  fistulous  communication  between  the  gall- 
bladder and  the  duodenum  was  not  working  well.  At  the  autopsy 
it  was  found  that  the  carcinoma  had  recurred  in  the  head  of  the 
pancreas  and  duodenum,  closing  the  common  duct  and  inter- 
fering with  the  perfect  action  of  the  cholecysto-enterostomy  or 
cystico-enterostomy.  The  anastomosis,  as  Ave  had  supposed,  had 
been  made  between  the  dilated  cystic  duct  and  the  duodenum; 
the  fistula  was  still  perfectly  pervious,  and  should  have  acted 
nicely  except  for  the  interference,  a  little  twisting  or  bending, 
created  by  the  new-growth." 


A  STUDY  OF  328  OPERATIONS  UPON  THE  GALL- 
BLADDER AND  BILE-PASSAGES* 

WILLIAM    J.    MAYO 


From  June  24,  1891,  to  February  28,  1902,  328  cases  of  gall- 
stone or  other  disease  involving  the  gall-bladder  and  bihary  pas- 
sages were  operated  upon  at  St.  Mary's  Hospital.  This  number 
includes  all  the  cases  of  this  description  which  were  admitted  to  the 
hospital  during  this  period.  A  study  of  these  cases  brings  out 
some  general  features  of  interest.  Three  hundred  and  eleven  of 
the  number  were  of  benign  origin.  The  mortality  following  opera- 
tion was  about  23^  per  cent.  Seventeen  of  the  operations  were  for 
malignant  disease,  with  3  deaths,  a  mortality  of  nearly  18  per  cent. 

Location  of  the  Stones. — In  214  of  the  cases  the  stones  were 
located  in  the  gall-bladder  or  cystic  duct  or  both.  In  this  group 
there  were  2  deaths.  In  about  10  per  cent,  of  these  cases  there  was 
obstruction  of  the  cystic  duct  by  a  stone  or  stones,  in  either  case 
requiring  considerable  effort  to  dislodge  them.  The  after-history 
of  many  of  these  cases  in  which  the  cystic  duct  was  involved 
and  simply  cholecystostomy  performed  was  not  wholly  favorable. 
The  hospital  records  do  not  show  the  condition  of  these  patients, 
with  the  exception  of  those  readmitted  for  secondary  operation. 
But  the  number  of  these  cases  known  to  the  writer  as  having  had 
unpleasant  symptoms  subsequent  to  the  operation  leads  to  the 
belief  that  for  cases  in  which  the  cystic  duct  has  been  obstructed, 
or  in  which  stones  have  been  lodged  in  the  duct  for  a  length  of 
time,  cholecystostomy  is  insufficient,  and  the  gall-bladder  should 
be  extirpated  at  the  primary  operation  if  the  patient  is  otherwise 
in  good  condition.     A  large  percentage  of  cases  in  which  the  cystic 

*  Reprinted  from  "Annals  of  Surgery,"  June,  1902. 


OI'KUATIONS    OX    CALL-BLADDER    AND    IJILE- PASS  AGES  373 

(Iiicl  lias  l)('(Mi  iii\(»l\('(l  leads  to  such  H  disturbance  of  its  mechanism, 
by  stricture,  val\('  I'oriiiation,  or  other  unfavorable  condition,  that 
it  may  not  furnisli  adctiuute  drainage  to  tlie  gall-bladder.  In  some 
extreme  cases  the  gall-bladder  becomes  filled  with  mucus,  which  is 
expelled  through  the  duct  only  by  such  vigorous  contractions  as 
to  cause  an  occasional  colic,  or  a  mucous  fistula  is  left,  with  inter- 
mittent external  discharge.  In  other  cases,  at  the  secondary  opera- 
tion, the  gall-bladder  is  found  filled  with  bile  and  mucus,  develop- 
ing a  condition  in  which  exit  to  the  cystic  contents  is  less  easy  than 
entrance  of  bile.  In  many  instances  the  discomfort  is  slight  and 
passes  away  in  time,  but  there  is  a  large  number  of  cases  in  which 
this  interference  with  drainage  is  sufficent  to  give  symptoms  more 
or  less  permanent  in  character.  The  nature  of  the  difficulty  can 
be  aptly  compared  to  stricture  of  the  lacrimal  duct  or  urethra. 
Nearly  one-half  of  the  cholecystectomies  performed  were  secondary 
to  this  condition,  and  only  after  extirpation  of  the  gall-bladder  did  a 
permanent  cure  result. 

Stones  in  the  cystic  duct  are  often  more  easily  removed  with 
the  gall-bladder  than  without  it.  If  the  peritoneum  binding  it 
to  the  liver  be  divided  on  each  side,  the  connective  tissue  between 
can  be  easily  separated  with  the  finger;  by  using  the  gall-bladder 
as  a  tractor  and,  if  necessary,  dividing  the  peritoneal  and  muscular 
coats  just  above  the  cystic  duct,  the  mucous  tube  of  the  latter 
will  strip  out  readil3%  bringing  the  stone  with  it.  The  mucous  coat 
about  the  neck  of  the  gall-bladder  is  thick  and  separates  easily 
from  the  outer  coats,  while  the  fixation  by  adhesions  is  to  the  outer 
coats  alone.  At  the  fundus  the  mucous  membrane  is  less  easy  to 
separate,  and  a  combination  of  amputation  of  the  fundus  with  re- 
moval of  the  mucous  coat  from  the  lower  portion  of  the  gall-bladder 
and  cystic  duct  makes  cholecystectomy  a  safe  operation.  The 
drains  should  be  tied  to  the  stump  with  fine  catgut  to  prevent  dis- 
placement, and  a  strip  of  rubber  tissue  placed  between  the  drains 
and  the  stomach  to  prevent  adhesions.  The  catgut  fixation  sutures 
are  absorbed  before  it  is  necessary  to  remove  the  drains.  In  most 
cases  the  whole  gall-l)ladder  can  ])e  so  easily  removed  as  to  render 
this  stri])ping  of  the  mucous  membrane  unnecessary,  but  in  j)rimary 


374  WILLIAM   J.    MAYO 

stone  impactions  and  secondary  operations  for  stricture  it  serves  a 
good  purpose;  and,  as  it  leaves  a  pouch  composed  of  the  outer 
coats,  into  which  a  tube  drain  can  be  securely  fastened,  the  cystic 
duct  can  be  left  open  for  drainage  of  the  hepatic  ducts  in  cases  in 
which  an  infective  cholangitis  is  present.  Ligation  of  the  cystic 
duct  would  prevent  this  imperative  indication  (Davis).  To  leave 
the  cystic  duct  open  in  the  abdomen  for  this  purpose  without 
direct  and  complete  drainage  would  be  attended  with  more  danger- 
The  bile  itself  would  drain  safely  to  the  surface  with  ordinary  care 
in  placing  the  drains,  but  not  so  the  infected  material  from  the 
ducts.  If  there  is  no  infection  of  the  hepatic  and  common  ducts, — 
and  usually  there  is  none, — drainage  of  the  bile  to  the  surface  is 
unnecessary,  and  the  cystic  duct  can  be  closed  by  ligature.  Out  of 
33  cholecystectomies  we  had  but  1  death,  and  this  was  due  to 
ligation  of  the  cystic  duct  in  a  case  in  which  the  hepatic  ducts 
should  have  been  drained  through  it. 

Cholecystectomy  will  rapidly  gain  in  favor  and  will  undoubtedly 
supersede  cholecystotomy  in  a  large  group  of  cases. 

Stones  Outside  the  Bile  Tract:  13  Cases,  no  Deaths.-^-In  13 
cases  stones  were  found  outside  of  the  gall-bladder  and  biliary 
ducts.  In  some  the  calculi  were  encapsulated  in  the  adjacent 
liver  border,  forming  hard  nodules  from  which,  upon  incision, 
they  could  be  enucleated.  In  others  a  mass  about  the  fundus 
would  contain  a  number  of  stones,  with  perhaps  a  little  mucopuru- 
lent fluid.  Further  dissection  toward  the  cystic  duct  would  open 
a  functionating  organ  of  small  size,  with  every  evidence  that  it 
was  but  the  remains  of  the  gall-bladder. 

In  several  cases  we  have  opened  a  pocket  composed  of  the  re- 
mains of  the  fundus,  but  slightly  separated  by  ulceration  and  con- 
nective-tissue formation  from  the  neck  of  the  organ.  The  gall- 
bladder was  perforated,  and  the  extruded  stones  in  a  mass  of  ad- 
hesions communicated  freely  with  the  fundus,  or  perhaps  there 
were  several  such  pockets  lined  with  granulation  tissue  and  more 
or  less  separated  from  each  other. 

In  other  cases  the  stones  were  found  lying  in  a  pocket  outside 
the  gall-bladder,  with  adhesions  to  the  intestine,  but  communicat- 


opp:kations  on  gall-uladdeu  and  hilk-I'ahsaoes       375 

ing  with  neither.  The  fiiiidus  was  contracted  to  a  mass  of  scar 
tissue.  In  three  cases  we  found  stones  outside  the  gall-bladder 
without  communication  with  it,  but  with  a  fi.stulous  opening  into 
I  lie  intestine — twice  to  the  duodenum  and  once  to  the  transverse 
colon.  Removal  of  the  stone  in  these  cases  made  it  necessary  to 
close  the  fistulous  tract  connected  with  the  bowel. 

In  the  two  cases  in  which  the  duodenum  was  involved  the  friable 
nature  of  the  infected  tissues  and  the  deep  seat  of  the  area  to  be 
sutured  made  this  a  matter  of  considerable  difficulty,  and  one  case 
formed  an  intestinal  fistula  which  was  very  troublesome,  but  later 
healed.  In  both  of  these  cases  there  were  stones  in  the  gall- 
bladder, but  the  cystic  duct  was  totally  obstructed.  It  is  prol)able 
that  in  both  cases  the  stones  had  been  impacted  in  the  cystic  duct 
before  the  ulceration  took  place.  A  study  of  these  cases  leads  to 
the  belief  that  stones  passing  by  ulceration  and  perforation  from 
the  gall-bladder  and  cystic  duct  to  the  intestine  do  so  slowly,  and 
that  often,  if  not  usually,  cicatrization  takes  place  behind  before 
the  extrusion  into  the  intestine  is  accomplished.  The  next  most 
common  direction  for  stones  to  travel  is  toward  the  surface  of  the 
body.  The  gall-bladder  becomes  obstructed  at  the  cj^stic  duct  and 
its  contents  infected.  Adhesions  form  to  the  parietal  peritoneum, 
and  eventually,  by  ulceration,  work  to  the  surface  as  a  subcutan- 
eous abscess.  This  was  met  with  twice  in  this  series  of  cases,  and 
one  case  was  admitted  with  a  fistulous  opening  following  spon- 
taneous rupture.  In  a  considerable  experience  in  the  operative 
treatment  of  gall-stone  disease  in  private  houses  and  local  hospitals 
we  have  found  this  latter  condition  relatively  more  frequent  than 
in,  St.  Mary's  Hospital,  as  the  local  peritonitis  which  marks  these 
cases  prevents  their  transportation,  while  extensive  changes  at- 
tending the  extrusion  of  the  stones  into  the  intestine  may  give 
little  symptomatic  evidence  of  trouble. 

Cholecystitis. — In  this  group  were  34  cases  with  5  deaths.  This 
mortality  calls  attention  to  the  serious  nature  of  the  infections. 
All  the  cases  in  which  an  acute  suppurative  condition  existed  at 
the  time  of  the  operation,  with  or  without  stones,  and  all  cases  in 
which  the  gall-bladder  was  found  thickened  and  containing  more 


376  WILLIAM   J.    MAYO 

or  less  ropy  mucus  and  bile  or  sand-like  sediment,  ^^dthout  stones, 
were  classified  at  the  time  of  operation  as  cholecystitis.  It  would 
seem  that  the  difJerence  between  these  two  conditions  was  marked 
enough  to  render  a  double  classification  necessary,  and  that  the 
first  should  be  called  "suppurative"  and  the  second  "catarrhal" 
cholecystitis.  It  was  noted  in  the  group  which  might  be  termed 
catarrhal  that  cholangitis  was  more  frequently  an  accompaniment, 
although  usually  of  a  mild  and  irregular  type,  and  that,  after  the 
operation,  as  there  was  no  obstruction  by  stone  or  other"\;\ase  at  the 
cystic  duct,  an  extension  of  the  inflammatory  process  manifested 
itself  in  these  three  cases  and  death  resulted.  In  the  suppurative 
form  the  gall-bladder  was  comparable  to  a  closed  cavity  containing 
pus,  which  so  thoroughly  blocked  at  the  cystic  duct  as  to  prevent 
progressive  infection.  In  all  but  four  of  the  acute  empyemas  the 
stone  was  removed  at  the  primary  operation.  In  three  cases  the 
gall-bladder  was  also  shelled  out.  Two  patients  with  acute  em- 
pyema in  which  the  stone  was  removed  after  great  difficulty  de- 
veloped a  fatal  suppurative  cholangitis  after  cholecystotomy. 
One  of  these  patients  also  had  a  profound  jaundice,  with  purpura 
hsemorrhagica,  and  death  was  probably  as  much,  or  more,  a  result 
of  the  hemorrhage  as  from  the  progressive  infection.  The  stone 
in  this  case  was  impacted  at  the  juncture  between  the  common  and 
cystic  ducts,  obstructing  both.  The  other  case  was  typical — the 
removal  of  the  impacted  stone  allowed  the  septic  material  to  pene- 
trate the  ducts.  In  the  four  cases  in  which  the  gall-bladder  was 
drained,  and  on  account  of  the  serious  condition  of  the  patient,  no 
attempt  was  made  to  remove  the  obstruction,  each  one  recovered 
promptly,  and  the  stone  was  removed  at  a  secondary  operation 
with  the  gall-bladder. 

Cholecystitis,  with  or  without  obstruction  at  the  cj^stic  duct, 
is  the  most  dangerous  condition  for  which  we  are  called  upon  to 
operate,  and  although  the  patient  may  be  apparently  in  good 
general  condition,  progressive  infection  of  the  ducts  is  liable  to 
supervene.  In  acute  infections  little  manipulation  should  be 
made  and  quick  drainage  established.  If  a  stone  obstructs  the 
cystic  duct,  it  is  safer  to  leave  it  for  a  second  operation,  or,  as  we 


OPKUATIONS    ON    (iALL-HLADDKU    AM)    I1ILK-P.\>S.SAGES  377 

have  clone  of  late,  remove  the  entire  ^ail-hhulder  to  a  healthy  point 
proximal  to  the  stone.  With  the  excej)tion  of  these  four  cases,  all 
the  stones  have  been  removed  at  tlie  primary  operation  or  were 
discharged  through  the  fistula  later  in  some  of  the  earlier  cases. 
In  no  case  was  there  a  reformation  of  stone,  so  far  as  is  known. 
Gall-bladders  which  have  become  cystic  from  stone  obstructing 
the  cystic  duct,  and  in  which,  after  the  clear  mucus  is  dra^^•n  off, 
some  purulent  looking  fluid  comes  up  having  the  physical  appear- 
ance of  pus,  are  not  included  in  this  group.  These  cases  are  com- 
mon, and  are  classed  with  the  ordinary  obstructions  at  the  cystic 
duct  ill  whicli  the  stone  should  be  removed  at  the  primary  of)era- 
tion. 

Tiic  author  has  long  held  the  view  that  the  dependent  fundus 
is  an  important  mechanical  factor  in  that  it  favors  stone  formation 
in  cases  in  which  stagnation  of  the  bile,  infection  of  the  gall-bladder, 
and  some  interference  with  drainage  through  the  cystic  duct  are 
the  other  factors:  that  is  to  say,  if  the  cystic  duct  were  at  the 
bottom,  the  sediment  would  pass  out  first.  For  this  reason  it 
seems  that  cholecystitis  might  be  more  liable  to  exist  without  stones 
in  the  cases  in  which  the  fundus  was  above  the  level  of  the  cystic 
duct.  It  is  possible  that  the  permanent  elevation  of  the  fundus, 
produced  by  the  adhesion  to  the  abdominal  incision,  may  be  one 
cause  of  the  non-formation  of  new  stones  after  cholecystotomy. 

In  two  cases  acute  suppurative  cholecystitis  followed  typhoid 
fever,  in  each  instance  developing  suddenly — one  case  during  the 
third  week  and  the  other  during  the  fifth  week  after  the  beginning 
of  the  fever.  At  the  time  of  operation  the  typhoid  bacillus  was 
found  in  pure  culture,  and  the  patient's  blood  gave  the  Widal  re- 
action. In  both  cases  stones  were  present  in  the  gall-bladder,  but, 
on  going  into  the  history,  it  could  be  shown  almost  beyond  a  doubt 
that  the  gall-stones  existed  before  the  advent  of  the  typhoid,  and 
merely  determined  a  lowered  resistance.  In  taking  the  histories 
of  the  cases  of  gall-stones  operated  upon  at  St.  Mary's  Hospital, 
only  a  very  small  percentage  had  had  typlioid  fever  at  any  time. 
It  would  seem  that  the  etiologic  importance  of  typhoid  fever  in  the 
causation  of  gall-stones  had  been  overestimated. 


378  WILLIAM   J.    MAYO 

•  Cholecystotomy  has  been  made  by  introducing  into  the  gall- 
bladder a  rubber  tube,  the  size  of  a  lead-pencil,  wrapped  in  gauze, 
then  covered  with  rubber  tissue.  A  catgut  purse-string  suture  is 
then  placed  below  the  incision  in  the  fundus,  and  the  ragged  edge 
of  the  opening  in  the  gall-bladder  inverted  into  its  cavity  (Sum- 
mers). The  suture  is  then  pulled  taut,  compressing  the  packing 
about  the  tube  and  making  a  tight  joint;  the  drain  is  held  in  place 
by  a  catgut  suture.  If  the  gall-bladder  is  too  short  to  reach  to  the 
parietal  peritoneum  for  fixation,  a  few  strips  of  gauze  are  tacked  to 
it  with  catgut  and  form  an  extension  to  the  surface.  In  a  consider- 
able number  of  cases  the  drains  have  been  carried  out  through  a 
stab  wound  and  the  operative  incision  completely  closed.  In  the 
course  of  other  operations,  if  gall-stones  coexist,  a  stab  wound  prop- 
erly placed  enables  the  fundus  of  the  gall-bladder  to  be  drawn  out 
of  the  opening,  and  the  stones  can  be  removed  and  drainage 
established  by  the  aid  of  the  hand  inside  of  the  abdomen.  Unless 
it  is  necessary  to  remove  the  gall-bladder,  it  is  not  wise  to  break 
up  adhesions  beyond  a  point  necessary  to  explore  the  ducts  and 
manipulate  the  fundus.  Time  spent  in  separating  adhesions  un- 
necessarily, which  must  reform,  not  only  prolongs  the  operation, 
but  breaks  down  a  valuable  barrier  to  the  extension  of  the  in- 
flammatory process  and  opens  up  new  avenues  for  infection. 

Stones  in  the  Common  Duct:  31  Cases,  One  Death. — Stones 
were  found  in  the  common  duct  in  31  cases,  and  in  only  one 
case  was  it  possible  to  remove  the  stone  through  the  cystic  duct 
by  dilating  it.  This  was  a  lucky  accident,  as  I  am  convinced, 
from  frequent  failures,  that  attempts  of  this  kind  are  a  loss  of  time. 
In  29  cases  the  duct  was  incised  and  the  stones  removed.  In  5 
cases  this  was  accomplished  by  separating  the  gall-bladder  from 
the  liver  and  incising  the  free  surface  down  to  and  along  the  cystic 
duct  to  the  common  duct,  the  latter  being  incised  at  the  juncture. 

In  2  of  these  5  cases  the  cystic  duct  tore  completely  loose  from 
the  common  duct,  leaving  an  irregular  opening,  which  was  closed 
by  a  plastic  operation  upon  the  duct,  using  the  gall-bladder  de- 
nuded of  the  mucous  membrane,  except  at  one  point,  where 
enough  was  left  to  fill  the  gap.     The  remainder  of  the  outer  coats 


OPKUATIONS    ON'    GALL-IJLADDKH    AM)    HI  LK-PASSAGES  370 

of  the  gall-bladder  was  trimmed  to  a  convenient  sized  flap, 
wrapped  about  the  common  duct  and  held  by  a  few  catgut  sutures 
and  a  light  gauze  pack.  The  biliary  leakage  was  very  slight  in 
either  case,  and  lasted  but  a  few  days. 

In  the  large  majority  of  cases  of  stones  in  the  common  duct 
the  stones  were  movable,  and  in  two-thirds  of  the  cases  more  than 
one  stone  was  present  in  the  duct  (in  one  case  27  stones).  The 
typical  ball-valve  stone  of  Fenger  was  met  with  7  times.  As  a 
rule,  where  more  than  one  stone  was  present,  the  duct  was  suffi- 
ciently dilated  to  enable  the  introduction  of  the  finger  for  purposes 
of  exploration.  In  no  other  way  could  we  be  sure  that  we  had 
removed  all  the  stones.  In  5  cases  stones  were  present  in  the 
hepatic  ducts  also,  but  were  movable,  and  with  varying  difficulty 
were  brought  to  the  incision  in  the  common  duct  for  removal. 

In  2  cases  energetic  attempts  to  remove  all  the  stones  from  the 
lower  end  of  the  duct  or  a  diverticulum  from  it  resulted  in  forcing 
the  finger  well  into  the  duodenum,  probably  at  an  ulcerated  point, 
rather  than  at  the  site  of  the  papilla.  Fitz  has  shown  that  large 
stones,  as  a  rule,  pass  into  the  bowel  by  ulceration  rather  than  by 
dilating  the  papilla.  In  these  2  cases  the  contents  of  the  duodenum 
escaped  from  the  drainage-tubes  for  a  number  of  days,  causing 
rapid  emaciation.  One  patient  recovered  completely;  the  second 
left  the  hospital  after  seven  weeks  in  bad  condition,  and  eventually 
died  at  her  home  from  inanition.  This  was  the  only  death  in  this 
group. 

In  a  number  of  these  cases  the  head  of  the  pancreas  was  en- 
larged, and  in  6  cases  more  or  less  pancreatic  secretion  came  out 
with  the  bile,  excoriating  the  skin,  and  causing  a  peculiar  odor  to 
the  discharge  which  seems  to  characterize  it.  One  of  these  cases 
had  a  general  acute  eczema  involving  the  entire  body ;  all  the  cases 
recovered. 

Jaundice. — Jaundice  in  connection  with  stones  in  the  common 
duct  was  a  most  variable  feature.  In  many  cases  it  was  so  slight 
as  not  to  attract  especial  attention,  and  finding  stones  in  the  com- 
mon duct  was  a  surprise.  In  the  majority  of  cases,  however,  the 
jaundice  was  marked.     Courvoisier  long  ago  called  attention  to  the 


380  willia:vi  j.  ^l\to 

fact  that  jaundice  from  stone  in  the  common  duct  was  accompanied 
by  a  contracted  gall-bladder,  which  could  not  be  palpated  ex- 
ternally in  80  per  cent,  of  the  cases.  This  was  true  of  all  but  3  of 
our  cases,  in  which  the  gall-bladder  was  filled  with  stones,  prevent- 
ing the  usual  contraction. 

Jaundice  as  a  Cause  of  Postoperative  Hemorrhage. — In  3  cases 
capillary  oozing  was  a  most  serious  postoperative  comphcation. 
One  case  was  in  a  precarious  condition  for  twelve  days  from  this 
cause.  Robson  has  called  attention  to  the  value  of  chlorid  of 
calcium  as  a  prophylactic  in  these  cases.  We  have  used  this  for 
about  one  year.  I  am  uncertain  as  to  its  value,  but  we  have  had 
no  deaths  from  hemorrhage  since.  One  case  of  empyema  of  the 
gall-bladder  complicated  vdih  extreme  jaundice  from  a  stone  im- 
pacted in  the  cystic  duct  at  its  juncture  with  the  common  duct, 
and  3  cases  of  jaundice  from  malignant  disease,  died  from  post- 
operative capillary  oozing.  In  all  these  cases  there  were  sub- 
cutaneous ecchymotic  spots,  looking  like  purpura  hsemorrhagica, 
before  operation.  Every  patient  with  jaundice  having  this  compli- 
cation died  after  operation  upon  the  gall-bladder.  Tests  as  to  the 
coagulability  of  the  blood  have  been  rather  uncertain,  but  this 
clinical  means  of  differentiating  the  operable  from  the  non-operable 
cases  has  been  impressed  upon  our  minds. 

After  removing  stones  from  the  common  duct  the  incision  is 
closed  by  a  continuous  catgut  suture,  providing  the  duct  is  in  good 
condition  and  no  fragments  of  stone  or  other  detritus  are  left 
behind;  otherwise  the  duct  is  partly  closed,  leaving  a  gap  for 
drainage.  If  the  patient  be  in  bad  condition,  drainage  is  employed 
without  suture.  The  suturing  is  done  -u-ith  a  single  row,  and,  if 
there  be  much  difficulty  in  doing  this,  only  enough  of  a  running 
suture  is  placed  to  direct  the  coaptation,  drainage  being  provided 
for  by  fastening  gauze  wdcks  covered  with  rubber  tissue  in  position 
with  the  catgut  suture,  to  prevent  displacement.  In  26  cases 
cholecystostomy  was  made  for  drainage.  In  2  cases  cholecystec- 
tomy was  performed,  the  cystic  duct  being  left  open  for  drainage. 
In  1  case  the  duodenum  was  incised  to  remove  a  stone  from  the 
ampulla  of  Vater. 


OIMOUATIONS    ON    GALL-IJLAODKR    AXD    BILPJ-PASSAGES  381 

Cholecystenterostomy  was  pcrfcMiiicd  .']  limes  for  flironic 
pancrcjilitis  and  3  limes  for  malignaiil  disease.  'J'lie  aiiasUjiiiosis 
was  made  to  the  duodenum  twice  and  to  tlie  transverse  colon  4 
times.  So  far  as  we  could  judge,  the  anastomosis  with  the  colon 
answered  every  purpose.  One  benign  case  lived  six  years  in  good 
health  and  died  from  other  causes,  and  a  second  is  alive  and  well 
now,  two  years  after  the  operation.  While  the  duodenum  is  the 
proper  place  for  the  anastomotic  opening,  it  sometimes  happens, 
by  reason  of  adhesions,  that  this  site  cannot  be  secured.  The 
transverse  colon  is  close  at  hand,  and  with  its  appendices — epi- 
ploica  and  omentum — furnishes  a  secure  situation  for  the  opening, 
and  the  operation  itself  may  in  this  way  be  easily  accomplished. 
There  are  many  theoretic  objections  to  it,  and  a  loop  of  jejunum 
would  seem  a  more  desirable  point  for  the  entrance  of  the  bile; 
however,  the  fact  remains  that  in  most  of  the  reported  cases  of 
anastomosis  between  the  gall-bladder  and  colon  the  results  have 
been  good.  The  Murphy  button  was  used  in  making  the  anas- 
tomoses. 

In  12  cases  an  exploration  showed  an  error  in  diagnosis.  This, 
however,  includes  only  the  cases  in  which  the  abdominal  wall  was 
incised  independently  for  this  purpose,  and  does  not  fairly  repre- 
sent the  mistakes.  In  some  of  the  earlier  cases  a  small  gall-bladder, 
with  thickened  walls  extensively  adherent,  was  found,  and  we 
contented  ourselves  with  loosening  the  adhesions.  Recovery 
followed  the  operation  in  each  instance,  and  the  symptoms  were 
usually  relieved.  In  a  few  cases,  however,  there  was  no  abate- 
ment of  the  previous  pain.  In  reoperating  upon  one  case  a  ball- 
valve  stone  of  small  size  was  found  in  the  common  duct,  yet  so 
little  jaundice  was  present  as  seemingly  to  preclude  the  possibility 
of  its  presence  in  this  locality.  In  two  cases  since  that  we  have 
found  a  rolling  stone  in  the  common  duct  under  preciseh'  similar 
circumstances.  Adhesions  about  a  small  gall-bladder  should  lead 
to  a  careful  exploration  of  the  common  duct  before  deciding  that 
the  adhesions  alone  are  the  cause  of  the  symptoms.  In  the  cases 
in  which  the  gall-bladder  was  explored  negatively  the  real  difficulty 
was  usually  an  old  appendicitis  or  ulcer  of  the  stomach     In  one 


382  WILLIAM   J.    MAYO 

case  a  stone  in  the  right  ureter,  and  once  a  small  ovarian  dermoid 
with  a  long  twisted  pedicle  was  found  to  be  the  source  of  trouble. 

The  abdominal  incision  for  work  upon  the  biliary  tract  which 
we  have  found  most  useful  has  been  the  straight  one  through  the 
rectus  muscle,  enlarged,  if  necessary,  either  at  the  top  or  bottom, 
after  the  method  of  Bevan,  with  the  modification  suggested  by 
Robert  Weir,  incising  the  sheath  of  the  rectus  muscle  and  the 
deeper  muscles  obliquely  and  retracting  the  rectus  itself  rather 
than  severing  it. 

Great  difficulty  in  exposing  the  gall-bladder,  especially  if  small 
and  under  the  liver,  may  be  experienced.  By  dividing  the  peri- 
toneum binding  the  gall-bladder  to  the  liver  and  separating  the 
cellular  space  between,  the  parts  can  usually  be  mobilized  without 
dividing  the  rib  cartilages.  The  venous  hemorrhage  is  quite  free 
for  a  short  time,  but  stops  after  temporary  gauze  packing,  and  in 
our  cases  has  never  been  a  serious  source  of  trouble. 

Of  the  8  deaths  in  the  benign  cases,  4  were  due  to  progressive 
infection  of  the  liver  ducts  with  late  kidney  complications,  1  from 
the  same  cause  with  capillary  hemorrhage,  and  1  sudden  death  due 
to  myocarditis,  which  was  recognized  previous  to  operation,  but 
the  danger  of  which  was  not  fully  appreciated.  Two  patients  died 
suddenly  on  the  fourth  day.  The  symptoms  after  the  operation 
consisted  of  a  peculiar  nervous  unrest,  pulse  110  to  120,  tempera- 
ture 100°  to  102°  F.,  gastro-intestinal  disturbance  not  marked,  but 
some  tympanitic  distention  shortly  before  death,  which  took  place 
unexpectedly.  The  postmortem  did  not  show  adequate  cause  for 
the  result.  The  condition  seems  to  correspond  with  that  described 
as  hepatargia  (Eisendrath) ,  and  due  to  cessation  of  liver  action. 
The  2  cases  belong  to  the  group  of  cholecystitis  without  stones. 
In  not  a  single  case  was  peritonitis  a  cause  of  death. 

Malignant  disease  involving  the  bile  tract  was  found  17  times; 
the  results  were  very  discouraging,  with  a  single  exception;  the 
palliation  secured  was  of  doubtful  character,  and  death  followed 
immediately  in  nearly  18  per  cent,  of  the  cases.  The  deaths  were 
due  to  capillary  hemorrhage,  and  all  these  cases  had  purpura 


OPERATIONS   ON    GAI-L-BLADDER   AND    BILE-PASSAGES  'iH'.i 

hsemorrhagica.     Stones   were  also   present  in   all  the   malignant 
cases  in  which  the  gall-bladder  and  dnc-ts  wore  explored. 

RfiSUMfi 

Operations  for  Nnii-malvjnaiil  Pinca.ic  of  the  Call-hladdcr  atiil  Bile-passagea  occur- 
ring in  Si.  Mary's  Ilo.spilal  from  June  2',,  1001,  to  February  20.  1002 

No.  Operated.  Recov.                Dii.d. 

CholcfVstosloMiv.     Sloncs  in  f,';ill-bl;i(l<lcT,  cystic 

duct'or  holh." •.  ...1!)!)  1!)7                         i 

Cholccystostoriiy.     Polypus  in  (jall-bladdcr I  1 

Cholccystostoiiiy.    (lall-hladdor  stone  with  acute 

pancreatitis  and  fal  tiecrosis 1  1 

CholccyslosLoniy.  Cholecystilis  with  and  with- 
out stones -26  22                       4 

Choledochotoniy.     Stones  in  common  duct 30  30* 

Choiecj'stectoniy.     (lall-stone  disease 24  24 

Cholecystectomy.     Cholecystitis 8  7                         1 

Cholecystectomy.  Cyst  of  gall-bladder  contain- 
ing ten  c|uarts,  suppo.sed  to  he  ovarian 1  1 

Cholccystcntcrostomy.    Chronic  pancreatitis  and 

jaundice  twice  with  gall-stones,  once  without.  .     3  3 

Division  of  adhesions 5  5 

Duodenocholedochotomy.     Stone  in  ampulla  of 

\'atcr 1  1 

E.xploratory.     \(>gativc 12  12 

311  304                      7 

Operations  for  Malignant  Disease 

No.  Operated.  Recov.                Died. 

Ciiolecystostomy.   Obstruction  of  common  duct  .4  2                        2 

Cholccvstectomv  and  partial  hepatectomy.  Can- 
cer df  gall-i)ladder 1  1 

Duodenocholedocliotomy.     Cancer  in  ampulla  of 

Vater 1  1 

Cholecystenterostomy.    Malignant  obstruction  of 

conuiion  duct 3  2                        1 

Exploratory.     Inoperable  cancer 8  8 

17  14                      3 
*One  case  died  after  leaving  the  iiospital  two  months  after  llie  operation. 


MALIGNANT  DISEASE  INVOLVING  THE  GALL- 
BLADDER* 

WILLIAM   J.    MAYO 


From  June  24,  1891,  to  September  23,  1902,  405  operations 
were  performed  for  all  causes  upon  the  gaU-bladder  and  biliary 
passages  in  St.  Mary's  Hospital.  Of  this  number,  20,  or  about 
5  per  cent,  of  the  operations,  were  for  malignant  disease.  While 
this  does  not  make  mahgnant  disease  a  common  malady,  it  is  of 
sufficient  frequency  to  merit  careful  attention.  The  true  propor- 
tion would  perhaps  be  somewhat  higher  than  5  per  cent.,  as  cancer 
of  the  gaU-bladder,  Hke  mahgnant  disease  of  most  of  the  internal 
organs,  is  slow  to  be  recognized,  and  is  often,  if  not  usually,  so  far 
advanced  as  to  render  even  an  exploration  unnecessary,  the  char- 
acter of  the  trouble  being  only  too  manifest  on  physical  examina- 
tion. 

It  is  a  question  whether  the  relative  number  of  cases  in  which 
cancers  of  the  gall-bladder  and  bile-passages  are  found  and  not 
subjected  to  operation  would  be  more  than  5  per  cent,  of  the  num- 
ber of  patients  with  gaU-stones  in  which  operation  is  refused  or  the 
true  nature  of  the  condition  is  not  recognized.  After  investigation 
of  the  subject,  Schroder  says  that  14  per  cent,  of  these  patients 
suffer  at  some  time  from  cancer  of  the  biliary  apparatus. 

This  brings  up  the  query  as  to  whether  there  is  an  etiologic  re- 
lationship between  gall-stone  disease  and  cancer  of  the  gall-bladder. 
Cour^^oisier  found  that  74  out  of  84  cases  of  malignant  disease  of 
the  gaU-bladder  had  gall-stones.  Siegert  states  that  in  95  per 
cent,  of  all  cases  of  primary  cancer  of  the  gall-bladder  gall-stones 

*Reprinted  from  "The  Medical  News,"  December  13,  1902. 
384 


MALIGNANT    DISEASE    IN'VOLVING    THE   GAI.L-HLADDEU  385 

are  present,  and  adds  the  significant  fact  that  calculi  are  found  in 
only  15  per  cent,  of  secondary  malignant  disease  of  this  organ. 

In  the  London  Cancer  IIos])ilal  Jicadles  found  that  in  4  cases 
of  primary  cancer  of  the  liver  gall-stones  were  present  in  all,  and 
in  36  secondary  cancers  of  the  liver  gall-stones  were  not  detected 
in  a  single  instance.  Musser  gives  the  percentage  of  gall-stones  in 
the  cases  of  primary  cancer  of  the  gall-bladder  which  he  found  re- 
corded as  69  per  cent.,  but  says  that  in  many  of  the  instances  in 
which  no  stones  were  discovered  it  was  probable  that  the  calculi 
had  passed.  In  all  the  explored  cases  of  cancer  of  the  gall-bladder 
in  our  own  series  gall-stones  were  present.  In  an  exhaustive  ex- 
amination of  the  subject  of  cancer  of  the  gall-bladder  and  bile- 
ducts  Kelynack  placed  the  proportion  of  primary  cancer  of  the 
gall-bladder  at  75  per  cent,  of  the  whole,  giving  25  per  cent,  as  the 
number  of  primary  cancers  of  the  bile-ducts.  Kelynack  called 
attention  to  another  noteworthy  fact:  that  cancer  of  the  gall- 
bladder is  at  least  three  times  as  frequent  in  women  as  in  men,  and 
that  this  proportion  is  also  true  of  gall-stone  disease. 

Siegert  found  79  females  to  14<  males.  Cancer  of  the  gall- 
bladder is  most  common  between  the  ages  of  fifty  and  sixt^',  which 
is  the  period  of  greatest  frequency  of  gall-stones.  Bland-Sutton 
states  that  columnar  epithelium  from  the  mucous  membrane  is 
the  type  of  the  carcinomatous  process,  but  says  that  in  most 
instances  it  could  not  be  determined  whether  its  origin  was  in  the 
mucous  glands  or  in  the  epithelium. 

It  is  to  be  noted  that  the  cholesterin  which  forms  the  chief  con- 
stituent of  gall-stones  is  also  a  product  of  the  mucous  membrane. 
Butlin  says  that  the  cancerous  ulcer  is  the  most  common  form. 
Bland-Sutton  has  found  general  carcinomatous  infiltration  of  the 
gall-bladder  forming  a  hard,  thick- walled  tumor,  with  a  small  cavity 
containing  stones,  to  be  the  more  common  variety,  and  with  this 
latter  group  could  be  placed  the  cases  which  we  have  recorded.  It 
will  be  observed  that  these  two  varieties  which  compose  the  ma- 
jority of  the  reported  specimens  not  only  contained  stones,  but 
the  primary  lesions  would  suggest  this  probable  source  of  irritation. 
Other  gross  forms  of  malignant  disease  of  the  gall-bladder  are  also 

VOL.  I — i5 


386  WILLIAM   J.    MAYO 

found,  particularly  that  type  in  which  a  tumor  projects  into  the 
cystic  cavity.  The  site  of  origin  of  cancer  in  the  gall-bladder  is 
usually  near  the  fundus,  although  a  considerable  number  have 
been  discovered  near  the  opening  of  the  cystic  duct.  Perforation 
into  the  peritoneal  cavity  and  general  peritoneal  infection  have 
rarely  taken  place.  The  viscera  may  be  found  studded  with  little 
cancerous  growths,  causing  ascites,  or  fistulous  openings  between 
the  gall-bladder  and  the  hollow  viscera  may  occur.  The  most 
common  method  of  extension  is  to  the  adjacent  liver,  either  directly 
or  through  the  blood-vessels,  and  to  the  lymphatic  glands  lying  in 
the  hepatic  fissure.  So  far  as  we  could  discover,  there  has  been 
no  recorded  case  of  operation  for  primary  sarcoma  of  the  gall- 
bladder, although  a  few  postmortem  specimens  have  been  exhibited. 
Musser  found  three  such  cases  recorded  in  the  literature. 

The  following  indisputable  facts  should  attract  attention: 
First,  gall-stones  are  almost  constantly  present  in  primary  malig- 
nant disease  of  the  gall-bladder  and  rarely  in  secondary;  second, 
the  relative  proportion  of  gall-stone  and  malignant  disease  of  the 
gall-bladder  in  women  and  men  is  practically  identical;  third,  the 
pathologic  lesions  found  are  best  explainable  on  this  hypothesis; 
and,  fourth,  the  similarity  in  age  frequency.  We  are  certainly 
warranted  in  concluding  that  gall-stones  are  the  most  important 
etiologic  factor  in  malignant  disease  of  the  gall-bladder.  Since  the 
relative  proportion  of  cancerous  disease  involving  the  gall-bladder 
and  bile  tract  and  simple  gall-stone  disease  was  one  in  20  in  the  405 
operations  upon  the  gall-bladder  and  bile-passages,  the  question 
assumes  practical  importance,  and  while  I  would  not  say  that  for 
this  reason  alone  gall-stones  should  be  removed,  it  certainly  aids 
in  deciding  that  early  removal  of  active  gall-stones,  other  things 
being  equal,  is  sound  surgery,  particularly  since  nearly  all  the 
mortality-giving  complications  are  the  result  of  delay.  In  over 
250  uncomplicated  gall-stone  operations  the  mortality  was  less 
than  1  per  cent. 

The  diagnosis  of  primary  cancer  of  the  gall-bladder  may  be 
easy.  As  a  rule,  a  hard  tumor  is  to  be  detected  in  the  region  of  the 
gall-bladder,  which  is  not  very  tender  to  touch,  and  unless  there 


MALIGNANT    DISKASE    IN\()L\"IN(;    TIIK    (JALL-HLADDKIt  887 

is  a  peritoneal  iiivcjheMiciit,  rigidity  oi  tlie  overlying  muscles  is 
not  marked.  There  is  j)ro^ressive  loss  of  flesh,  and  later  a  ca- 
chexia is  dcvclopc<i.  A  nodular  tumor  becomes  apparent  as  the 
liver  is  involved,  and  jaundice  from  extension  to  the  common  and 
hepatic  ducts  in  the  later  stages  may  occur.  A  ])revious  history 
of  f^all-stone  disease  can  usually  be  obtained.  Xaunyn  says  that 
at  least  one-half  of  the  cases  of  jaundice  diagnosticated  as  due  to 
gall-stones  are  caused  by  cancer  or  complicated  with  it.  In  our 
experience  this  percentage  is  too  high.  The  jaundice,  when  it 
exists,  is  persistent  and  unchanging,  and  if  a  tumor  is  present  and 
is  accompanied  by  loss  of  flesh  before  the  appearance  of  the  jaundice, 
there  can  be  but  little  doubt  as  to  the  malignant  nature  of  the 
trouble.  Courvoisier  long  ago  pointed  out  that  stone  in  the  com- 
mon duct  is  accompanied  by  a  contracted  gall-bladder  in  84  per 
cent,  of  cases,  and  in  the  early  stages  jaundice  is  intermittent  and 
often  accompanied  by  occasional  chills  and  fever,  due  to  an  ac- 
companying infective  cholangitis. 

We  have  seen  a  cystic  gall-bladder  of  long  standing,  due  to 
stone  impacted  in  the  cystic  duct,  give  rise  to  a  hard  tumor  re- 
sembling malignant  disease.  Occasionally  such  a  tumor  may  re- 
sult from  an  adherent  gall-bladder  shrunken  down  upon  a  mass  of 
stones.  The  local  tenderness  and  history  of  sudden  appearance, 
with  the  general  condition  of  the  patient,  will  usually  be  sufficient 
to  differentiate.  It  sometimes  happens  that  even  on  the  operating 
table  it  is  impossible  to  say  whether  or  not  a  thick-walled  gall- 
bladder is  malignant.  Robson  reports  a  case  in  which  no  fluid  was 
found  on  puncture,  but  the  hardness  of  the  enlarged  gall-bladder 
and  the  bad  general  condition  of  the  patient  led  him  to  the  con- 
clusion that  it  was  malignant  disease.  Drainage  was  established, 
and  permanent  recovery  followed.  Abbe  reports  an  almost  iden- 
tical case.  The  opposite  mistake  may  also  be  made.  The  follow- 
ing is  the  report  of  a  case  which  occurred  in  St.  Mary's  Hospital: 

Case  I. — Cholecystotomij  for  Gall-stone  Disease.  Unsuspected 
Malignancy. — Mrs.  J.  R.,  age  sixty-four  years,  admitted  to  the 
hospital  September  9,  1901.  The  following  history  obtained. 
For  some  years  patient  had  suffered  from  typical  gall-stone  colic. 


388  WILLIAM   J.    MATO 

In  September,  1900,  had  a  very  severe  attack,  during  which  her 
physician  could  distinctly  feel  the  enlarged  gall-bladder.  This 
was  suddenly  relieved  and  the  tumor  disappeared.  She  has  lost 
a  great  deal  in  weight  and  is  in  constant  pain. 

Physical  Examination. — Patient  cachectic,  slightly  jaundiced; 
liver  dulness  indefinite,  perhaps  slightly  enlarged.  No  tumor  could 
be  felt  on  palpation.     Nothing  else  of  importance  was  noted. 

Diagnosis. — From  the  history  a  diagnosis  of  gall-stone  disease 
was  made. 

Operation. — On  September  10,  1901,  through  the  usual  incision, 
an  exceedingly  adherent  and  very  thick-walled  gall-bladder  was 
exposed.  In  the  small  central  cavity  a  few  gall-stones  were  found. 
One  stone  was  impacted  in  the  cystic  duct.  The  patient  was  in 
bad  general  condition,  and  drainage  of  the  gall-bladder  was  in- 
stituted. Cholecystectomy  would  otherwise  have  been  done.  No 
suspicion  existed  that  the  gall-bladder  was  cancerous.  The  con- 
dition was  supposed  to  be  due  to  inflammatory  thickening.  Pa- 
tient was  discharged  in  three  weeks.  The  relief  obtained  from  the 
operation  was  but  temporary.  The  pain  returned,  and  a  tumor 
soon  afterward  appeared  and  rapidly  enlarged,  followed  later  by 
jaundice  and  death  about  four  months  after  the  primary  operation. 

Cholecystectomy  is  gradually  displacing  drainage  in  the  class 
of  cases  accompanied  by  marked  changes  in  the  wall  of  the  gall- 
bladder, and  it  is  probable  that  many  early  cases  of  cancer  will  in 
this  way  be  discovered  and  renioved.  Practically  all  the  patients 
not  operated  die  within  the  year,  although  a  few  have  been  reported 
in  which  life  was  prolonged  nearly  two  years.  Musser  says  that 
only  a  few  months  of  life  is  to  be  expected,  and  that  this  has  not 
been  prolonged  by  operation  in  the  majority  of  the  reported  cases. 
The  first  removal  of  the  gall-bladder  for  malignant  disease  took 
place  in  1887.  The  number  of  cases  reported  is  small.  Robson 
had  4  cases,  of  which  1  died  as  a  result  of  the  operation.  Butlin 
collected  15  cases  operated  upon  with  12  recoveries,  and  of  these 
9  died  from  recurrence  within  four  months  because  of  inefficient 
removal. 

The  following  2  cases  are  of  interest  in  this  connection: 

Case  II. — Cholecystectomy  for  Cancer  of  the  Gall-bladder.  Re- 
currence after  One  Year. — Mrs.  M.  H.,  age  sixty-three  years,  Amer- 


MALIGNANT    DISEASE    INVOLVINf;    THK    (;ALL-HLADDER  38!) 

lean,  housewife,  widow.  Admit  ted  to  Si.  .Mary's  Hospital  .June 
1*2,  lf)()l,  will)  I  lie  following  liislory:  For  some  years  lias  had  oc- 
casional attacks  of  cramps  in  the  stomach  lasting  from  a  few 
minutes  to  several  hours,  and  necessitating  the  exhibition  of 
niorphin  for  relief.  For  three  months  there  has  been  a  steady 
boring'  pain  in  the  region  of  the  gall-bladder,  extending  through  to 
the  back.  There  has  been  considerable  loss  of  flesh.  In  the 
early  history  some  transient  attacks  of  jaundice  followed  the  spells 
of  pain,  although  the  icterus  was  never  marked.  Personal  and 
family  liistory  otherwi.se  negative. 

Physical  examination  revealed  nothing  beyond  a  deep-seated 
resistance  in  the  region  of  the  gall-bladder. 

Diagnofiis. — Gall-stone  disease. 

Operation  June  15,  1902.  A  thick-walled  gall-bladder,  densely 
adherent,  and  containing  a  few  small  gall-stones  in  its  nearly 
obliterated  cavity.  The  appearance  was  suspicious,  and  the  gall- 
bladder was  dissected  out  and  drainage  established.  Di.scharged 
in  three  w'eeks.  Unfortunately,  the  specimen  was  lost,  and  it  was 
not  until  the  patient  presented  herself  with  the  sub.sequent  history 
that  the  diagnosis  was  established.  She  had  remained  well  for 
over  a  year.  July  2,  1902,  began  to  have  a  return  of  the  pain  and 
a  jaundice  developed.  An  irregular,  deep-seated  tumor  at  the 
site  of  former  operation  could  be  discovered  on  deep  palpation. 

Case  111.— Cholecystectomy  for  Cancer  of  the  Gall-bladder. 
Recovery. — Mrs.  T.  McD.,  Irish,  married,  housewife,  aged  fifty-six 
years,  was  admitted  to  St.  Mary's  Hospital  June  19,  1902,  with 
the  following  history:  For  several  years  has  been  subject  to  attacks 
of  cramping  pain  in  the  stomach  lasting  from  a  few^  minutes  to 
several  hours.  For  the  past  year  these  attacks  have  increased  in 
severity,  and  for  several  months  the  pain  has  been  more  or  less 
continuous,  accompanied  by  loss  of  flesh  and  some  jaundice.  The 
latter  symptom  has  been  variable,  but  never  entirely  absent. 
History  otherwise  negative. 

Examination. — Patient  shows  loss  of  flesh  and  strength,  some- 
what jaundiced;  pulse,  110;  temperature,  97.5°  F.  Trace  of  albu- 
min and  considerable  bile  in  urine.  Liver  dulness  increased;  no 
tumor  in  region  of  gall-bladder;  tender  to  pressure  in  the  epi- 
gastrium and  right  hypochondriac  region. 

Diagno.si.s. — Gall-stones  with  probable  stone  in  common  duct. 

Operation  June  21,  1902.  Straight  incision  through  right  rectus 
muscle.     Gall-bladder  buried  in  a  mass  of  adhesions.     It  is  of  small 


390  WILLIAM   J.    MAYO 

size,  with  great  thickness  of  the  walls.  Stone  obstructing  cystic 
duct  at  its  juncture  with  the  common  duct  apparently  compressing 
the  latter.  Appearance  of  gall-bladder  suspicious.  Cholecystec- 
tomy with  hepatic  drainage  through  cystic  duct.  Discharged  in 
twenty-four  days.     Specimen  shows  carcinomatous  infiltration. 

In  a  number  of  instances  the  adjacent  liver  has  been  involved, 
and  yet  the  diseased  process  was  sufficiently  localized  to  permit 
of  resection  of  the  infiltrated  parts.  The  surgical  treatment  of  such 
tumors  has  been  thoroughly  reviewed  by  Keen,  Terrier,  and  others, 
and  personal  cases  reported.  When  complicated  with  jaundice, 
the  mortality  is  very  high.  The  following  case  illustrates  the 
condition  found  in  a  more  advanced  case: 

Case  IV. — Cholecystectomy  and  Partial  Hepatectomy  for  Cancer 
of  the  Gall-bladder  Involving  the  Liver.  Recovery,  Followed  by  Re- 
currence.— Mrs.  E.  R.,  American,  age  sixty -five  years,  was  ad- 
mitted to  St.  Mary's  Hospital,  Rochester,  Minnesota,  April  18, 
1900. 

History. — She  has  been  in  her  usual  health  until  within  last 
six  months.  During  this  time  she  has  suffered  from  a  boring  pain 
in  right  side,  which  of  late  has  become  almost  constant.  Stomach 
symptoms  have  been  of  moderate  severity.  There  have  been  some 
loss  of  appetite  and  constipation,  with  a  decrease  of  15  pounds  in 
weight.  No  jaundice  nor  history  of  colics.  Examination  reveals 
a  somewhat  movable  tumor  in  the  right  hypochondriac  region, 
evidently  connected  with  the  liver.  The  mass  has  a  nodular  feel. 
Exploratory  incision  April  21, 1900.  A  carcinomatous  gall-bladder 
involved  the  adjacent  portion  of  the  liver  and  the  cystic  duct. 
There  was  some  infiltration  along  the  common  duct  and  extending 
to  the  duodenum,  upon  which  at  one  place  there  was  a  considerable 
area  of  adhesions.  A  few  glands  in  the  angle  between  the  cystic 
and  hepatic  ducts  were  infected.  The  disease  was  so  definitely 
circumscribed,  with  such  slight  glandular  involvement,  that  the 
removal  of  the  affected  area  was  decided  on.  The  excision  was 
begun  at  the  common  duct,  two  inches  of  which  was  removed  with 
one-half  inch  of  the  hepatic  duct.  The  vessels  were  caught  and 
tied  as  divided;  an  area  of  adherent  duodenum  the  size  of  a  silver 
half-dollar  was  included  in  the  excision.  The  opening  in  the  in- 
testine was  closed  by  circular  purse-string  suture.  The  lower  end 
being  thus  free,  the  gall-bladder  with  the  attached  liver  was  re- 


MALIGNANT    DISEASE    IWOLVIN'G    THE    GALL-BLADDKIt         3f)l 

moved  with  the  Paquclin  cautery  knife.  The  larger  vessels  were 
grasped  with  forceps.  The  free  venous  oozing  from  the  liver  sub- 
stance was  not  controlled  hy  the  cautery,  although  easily  checked 
by  slight  pressure,  the  blood-currcut  being  of  little  force.  A  piece 
of  sterile  gauze  the  size  of  the  wrist  was  placed  in  the  cavity,  and  a 
continuous  suture  of  fine  catgut  was  run  through  the  liver  sub- 
stance on  each  side  of  and  around  the  gauze,  compressing  the  bleed- 
ing liver  margins  against  it,  and  efficiently  controlling  the  hemor- 
rhage. The  portal  vein  was  exposed  to  a  considerable  extent  in  the 
bottom  of  the  cavity.  Adequate  drainage  was  afforded,  the  bile 
being  conducted  to  the  surface.  Recovery  was  uneventful.  The 
gall-bladder  contained  a  single  stone,  three-fourth  inch  in  diameter. 
Patient  died  four  months  after  the  operation  from  recurrence. 

So  far  as  I  have  been  able  to  discover,  all  the  cases  in  which  the 
liver  was  involved  secondary  to  primary  cancer  of  the  gall-bladder 
have  had  early  recurrence.  This  is  also  true  of  the  cases  in  which 
the  lymphatic  glands  in  the  fissure  of  the  liver  were  infected. 
Jaundice  occurs  in  about  one-half  of  the  cases,  and  as  it  is  a  late 
symptom,  operation  is  contraindicated.  The  increasing  frequency 
of  operation  for  gall-stone  disease  will  lead  to  the  accidental  dis- 
covery of  cancer  in  an  early  stage,  and  the  results  of  operative 
interference  will  vastly  improve. 


THE  PRESENT  STATUS  OF  SURGERY  OF  THE 
GALL-BLADDER  AND  BILE-DUCTS* 

WILLIAM    J.    MAYO 


The  medical  profession  has  been  somewhat  slow  to  accept  the 
modem  view  regarding  gall-stone  disease,  and  it  is  far  from  having 
the  definite  solution  which  has  been  given  the  "appendicitis 
problem."  The  reasons  for  this  are  apparent,  and  based  upon 
fairly  reliable  grounds.  The  patient  is  usually  along  in  years,  and 
often,  by  reason  of  degenerative  lesions  or  adipose  tissue,  not  a 
good  subject  for  operation,  and,  again,  death  does  not  come  with 
that  tragic  suddenness  which  ofttimes  characterizes  appendicitis. 
But  all  these  considerations  are  of  minor  importance  when  com- 
pared to  the  major  obstacle  to  a  proper  understanding  of  this 
common  malady,  which  is  by  no  means  the  innocent  disease  our 
predecessors  have  taught  us  to  believe.  It  is  the  "slumbering 
gall-stone"  which  stands  in  the  way  of  diagnosis.  Riedel  esti- 
mates that  2,000,000  Germans  have  gall-stones,  and  of  these,  only 
100,000  have  symptoms.  Kehr  states  that  10  per  cent,  of  adults 
have  gaU-stones,  and  only  5  per  cent,  of  these  have  trouble  result- 
ing therefrom.  Bevan  found  that  16  per  cent,  of  the  cadavers  at 
the  Rush  dissecting-rooms  had  gall-stones,  but  he  also  called  at- 
tention to  the  significant  fact  that  the  material  was  drawn  from 
almshouses  and  charity  institutions.  Bevan  says,  "this  does  not 
fairly  show  the  true  percentage,  because,  as  a  class,  these  cadavers 
represent  the  people  who  have  seen  the  hardest  side  of  life."  This 
comment  is  just,  and  applies  equally  to  all  the  collected  statistics, 
as,  almost  without  exception,  they  are  drawn  from  large  hospitals 

*  Read  by  invitation  before  the  Academy  of  Medicine,  New  York,  December 
18,  1902.     Reprinted  from  the  "Medical  Record,"  February  21,  1903. 

392 


STATUS    OF    SURGERY   OF    GALL-BLADDER    AND    BILE-DUCTS      393 

and  similar  instiliilioiis.  This  very  fact  indicates  tlial  the  pa- 
tients ninst  have  been  in  a  condition  in  which  the  two  cardinal 
factors  ill  gall-stone  formation  were  most  likely  to  he  present:  de- 
fective circulation  of  bile,  and  that  mild  infection  aptly  termed 
"stone-building  catarrh." 

It  is  altogether  probable  that  the  accepted  percentage,  as 
api)lied  to  the  public  at  large,  is  too  high;  yet  even  if  5  percent, 
of  adults  have  gall-stones  and  95  per  cent,  of  these  peacefully 
"slumber,"  it  makes  the  physician  pause  before  recommending 
an  operation.  The  chance  of  picking  out  the  surgical  case  would 
be  but  1  in  20.  This  is  not  the  fact,  for  if  the  calculi  are  really 
latent,  one  does  not  know  of  their  presence  unless  discovered  during 
a  surgical  operation  for  some  other  purpose. 

The  removal  of  slumbering  gall-stones  under  such  circum- 
stances can  be  compared  to  normal  appendectomy.  I  do  not  wish 
to  be  understood  as  not  advising  the  removal  of  latent  calculi  on 
such  occasions,  provided  it  does  not  seriously  add  to  the  general 
operative  risk,  especially  as  intelligent  examination  of  the  patient's 
history  will  often  develop  certain  gastric  symptoms  which  were 
due  to  this  cause,  and  from  which  relief  is  thereby  obtained.  We 
have  grown  so  accustomed  to  looking  upon  the  colic  as  the  one 
symptom  of  gall-stones  that  we  often,  if  not  usually,  overlook  its 
more  chronic  manifestations. 

The  proportion  of  actually  "slumbering"  gall-stones  is  mucli 
less  than  we  have  heretofore  believed.  In  a  considerable  number 
of  cases  the  term  is  a  relative  one,  and  means  that  the  disturbance 
is  so  slight  that  the  cause  is  unsuspected. 

This  brings  us  to  the  question — what  causes  latent  calculi  to 
become  active.^  There  are  two  explanations:  one,  that  of  Kehr, 
which  lays  everything  to  an  infection,  and  the  more  generally 
adopted  cause,  of  mechanical  interference  with  drainage  from  the 
gall-bladder.  As  a  matter  of  fact,  both  causes  are  usually  present, 
the  one  depending  upon  the  other.  If  the  circulation  of  bile  is 
free,  the  germs  will  be  mechanically  w^ashed  away,  so  that  lack  of 
drainage  is  a  most  important  element.  On  the  other  hand,  in- 
fection acts  as  an  irritant  to  the  gall-bladder,  and  generally  induces 


394  WILLIAM   J.    MAYO 

the  contractions  which  engage  the  stone  at  the  entrance  of  the 
cystic  duct.  In  other  cases  the  swelhng  of  the  gall-bladder  and 
ducts  from  the  infection  causes,  of  itself,  mechanical  obstruction. 
The  resulting  disturbance  depends  upon  the  acuteness  of  the  in- 
fection and  upon  the  ability  of  the  organ  to  distend.  The  gall- 
bladder, in  this  respect,  has  the  advantage  over  the  appendix,  as 
well  as  a  far  better  blood-supply.  Rupture  and  gangrene  are, 
therefore,  rare,  and  sudden  death  from  fatal  perforation  does  not 
often  occur.  The  appendix  and  gall-bladder  are  both  dependent 
organs  with  a  limited  outlet  and  liable  to  stone  formation,  but  the 
grade  of  infection  in  the  gall-bladder  is  usually  mild  in  character, 
while  its  distensibility  equalizes  the  tension  which  is  so  fatal  a 
factor  in  the  appendix,  containing,  as  it  does,  the  most  virulent  of 
bacteria. 

The  infection  in  the  gall-bladder  may  die  out,  especially  colon 
infections,  but  this  is  not  to  be  expected.  Normal  bile  is  free  from 
microorganisms,  as  shown  by  Netter  and  Naunyii.  In  15  cases 
Mieczkowski  aspirated  bile  from  a  normal  gall-bladder  during  a 
laparotomy  for  other  purpose,  and  in  every  case  the  bile  was  sterile. 
Frankel,  Krause,  and  others  found  normal  bile  to  be  a  poor  culture- 
medium,  but  thick,  stagnant  bile  a  fairly  good  one.  Bacteria 
may  remain  in  an  attenuated  condition  a  long  time  in  the  gall- 
bladder, but,  as  proved  by  Miquot  and  Miyoke,  capable  of  return 
to  virulence  under  favorable  circumstances. 

The  calculus  gall-bladder  was  found  by  Mikulicz  to  contain 
bacteria  in  18  out  of  23  cases,  and  numerous  observers  have  con- 
firmed these  results.  We  may  take  it  for  granted  that  all  cases  of 
slumbering  gall-stones  contain  bacteria  encapsulated,  perhaps, 
like  in  an  old  osteomyelitis,  needing  only  some  interference  with 
drainage  to  start  into  activity;  or  reinfection  from  the  intestine 
may  occur,  either  directly  or  by  way  of  the  portal  circulation  and 
bile  itself. 

Under  favorable  circumstances  troublesome  gall-stones  may 
again  rest,  and  the  various  medicinal  springs  which  have  obtained 
a  reputation  in  the  treatment  of  biliary  calculus  probably  act  by 
keeping  up  that  free  circulation  of  bile  which  is  so  essential  to  the 


STATUS    OF    srUCKHV    OK    (JALL-MLADDKU    AM)    I$n.F:-r)rrTS       30.5 

\v(>lI-l)(Mii<,'  of  flic  liosL  The  active  gall-stone,  so  loii;,'  as  it  has 
{)erio(ls  of  latency,  is  a  (icl)atal)le  sul)ject,  and  can  l)e  claimed  })y 
either  the  internist  or  the  snrj^eon.  It  is  the  ease  of  chronic  and 
relapsing  appendicitis  over  again.  The  age  and  general  condition 
of  the  patient  will,  however,  be  a  more  dominant  factor  in  this  class 
of  cases  than  in  disease  of  the  appendix.  The  question  for  consid- 
eration is  whether,  in  view  of  the  possil)ility,  nay,  i)rol)al)ility,  of 
further  extension  of  the  trouble,  it  is  not  wise  to  remove  active  gall- 
stones early.  The  results  of  early  operation  for  gall-stone  disease 
are  remarkably  good.  Up  to  December  11,  190'-2,  we  had  about  250 
cases  of  this  kind  out  of  a  total  of  454  operations,  with  a  death-rate 
of  less  than  1  per  cent.  Robson,  Kehr,  Ochsner,  Murphy,  Richard- 
son, and  {)ractically  all  surgeons  with  a  large  experience  give  sta- 
tistics which  tell  the  same  story.  In  over  !2000  operations  of  this 
kind,  in  the  hands  of  six  surgeons,  there  was  not  a  single  instance  of 
reformation  of  the  gall-stones.  In  this  field  of  surgery  delay 
breeds  misfortune. 

Complications  are  due  to  changes  in  the  wall  of  the  gall-bladder 
or  involvement  of  the  bile-ducts,  and  the  calculi  may  become  but 
an  incident  in  the  pathologic  process  which  they  initiated.  Re- 
peated infections  with  prolonged  interference  with  drainage  cause 
the  walls  of  the  viscus  to  become  infiltrated  with  inflammatory 
products,  and  the  connective  tissue  formed  interferes  with  its 
elasticity  under  pressure  and  limits  its  power  of  contraction.  This 
introduces  the  element  of  tension,  and  results  in  more  marked 
symptoms,  as  pointed  out  by  Berg.  The  struggle  is  now  to  a  finish, 
and  either  the  obstructing  stone  is  forced  through  the  cystic  duct 
into  the  common  duct,  to  remain  there,  or  to  pass  out  into  the 
intestine,  or  it  may  become  encysted  in  a  thick-walled  pouch  com- 
posed of  the  remains  of  the  gall-bladder,  causing  recurring  attacks 
of  inflammation.  The  variety  of  changes  found  in  the  gall-bladder 
remind  one  of  a  chronic  appendicitis,  in  which  deformed  and  par- 
tially obliterated  forms,  with  stones  encapsulated  ofttimes  in  the 
surrounding  tissues,  are  not  uncommon.  Adhesions  to  surround- 
ing viscera  may  prevent  fatal  perforation,  or  divert  it  into  a  neigh- 
boring viscus  with  spontaneous  discharge  of  the  infected  fluid,  and, 


396  WILLIAM   J.    INIAYO 

incidentally,  of  the  calculi.  Even  if  all  the  stones  are  so  discharged, 
which  does  not  often  happen,  the  adhesions  remaining  may  be  a 
prolonged  source  of  distress  to  the  patient.  An  operation  in  this 
stage  is  fraught  with  some  danger,  and  the  gall-bladder  can  no 
longer  be  expected  to  return  to  the  normal.  It  may  do  so,  but  in  a 
number  of  cases  interference  with  drainage,  due  to  some  permanent 
change  in  the  cystic  duct,  gave  rise  to  colics  or  pain. 

It  is  in  this  class  of  cases  that  cancer  of  the  gall-bladder  is  most 
liable  to  supervene.  In  454  operated  cases  we  found  cancer  of  the 
gall-bladder  or  bile-ducts  in  21  (5  per  cent.),  and  in  nearly  all  a 
distinct  history  of  previous  colics  was  elicited.  All  the  cases  in 
which  the  gall-bladder  was  examined  contained  stones.  The 
chronic  irritation  of  calculi  in  a  gall-bladder  in  which  inflammatory 
changes  have  taken  place  seems  to  be  the  usual  precancerous  con- 
dition. This  is  certainly  a  serious  factor  in  deciding  operation — a 
l-to-20  chance  is  not  to  be  risked  lightly. 

The  possibility  that  all  the  stones  may  be  expelled  through  the 
ducts  is  alluring  to  both  the  physician  and  the  patient.  This  may 
happen,  but  we  have  never  operated  upon  a  case  in  which  the 
patient  brought  us  stones  detected  in  the  feces  that  the  gall- 
bladder did  not  contain  more. 

In  49  of  our  cases  stones  were  found  in  the  common  and  hepatic 
ducts,  ^ath  or  without  jaundice,  but  in  any  event  necessitating  a 
serious  operation.  Robson  found  stones  lodged  in  the  common 
duct  in  20  per  cent,  of  his  cases.  Evidence  that  a  stone  has  success- 
fully passed  into  the  intestine  does  not  contraindicate  operation; 
it  is  altogether  probable  that  more  stones  remain,  and  the  next 
"labor"  may  end  prematurely,  leaving  one  or  more  stones  in  the 
duct.  Occasionally  one  finds  a  case  in  which  such  stones  have  re- 
mained for  years  in  the  common  or  hepatic  ducts  with  compara- 
tively little  trouble;  but  such  instances  are  rare,  and  the  rule  is 
that  infections  of  the  liver-ducts,  and  occasionally  those  of  the 
pancreas,  render  surgical  intervention  a  necessity,  but  with  the 
jaundice  which  usually  coexists  the  operation  is  far  from  safe. 

Infection  of  the  liver-ducts  introduces  an  element  of  uncer- 
tainty in  the  prognosis,  and  to  this  cause  the  majority  of  deaths 


STATUS    OF    Sf'UGEUY    OF    (; ALL-HLADDKK    AND    JHLK-lJl  (  TS       'V.)7 

afler  operation  may  be  traced.  In  these  cases  the  condition  de- 
scribed as  "hcpatarjila,"  or  cessation  of  liver  function  from 
degeneralron  of  the  Uver  parenchyma,  may  be  present.  (Quincke 
found  that  chohingitis,  secondary  to  colon  infection  of  the  gall- 
bladder, was  more  liable  to  cause  acute  liver  degeneration  than 
when  due  to  the  ordinary  pus  microorganisms,  although  this 
bacillus  has  a  shorter  life  history.  Talma  demonstrated  that  either 
colon  or  typhoid  bacilli  injected  into  the  gall-bladder  would  not 
infrociucntly  travel  up  the  hepatic  ducts  and  cause  extensive  patho- 
logic changes  in  the  liver.  Lavastine  recently  reported  six  autop- 
sies in  cases  of  acute  liver  insufficiency  in  which  these  changes  were 
most  marked.  In  our  experience  this  has  been  the  cause  of  death 
in  nearly  one-half  of  the  cases.  The  symptoms  of  this  condition 
are  chiefly  nervous — usually  sudden  in  onset  and  rapid  in  their 
course.  The  only  safeguard  in  operating  upon  cases  with  infective 
cholangitis  is  free  drainage  of  the  bile  to  the  surface. 

In  1897  we  operated  upon  two  cases  in  which  the  diagnosis  of 
gall-stones  seemed  certain,  and  in  neither  case  were  calculi  found. 
The  gall-bladder  was  not  opened,  although  its  walls  were  thickened 
and  lacked  that  peculiar  bluish-green  color  characteristic  of  it 
when  filled  normally  with  bile.  The  operation  was  thought  to  be 
a  mistake  in  diagnosis.  About  this  time  we  had  several  cases  in 
which  we  could  not  be  sure  whether  or  not  the  unopened  gall- 
bladder contained  calculi.  In  2  instances  the  gall-bladder  was 
incised;  no  stones  were  found,  but  it  contained  thick  mucus  and 
bile.  These  patients  were  cured  by  drainage.  During  the  next 
two  years  we  had  a  small  number  of  such  cases,  and  finally  re- 
operated  upon  the  two  original  patients,  in  whom  the  symptoms 
had  continued,  and  obtained  a  cure  in  each. 

In  454  cases  we  have  had  26  of  this  description, — evidently  a 
chronic  cholecystitis  without  stones, — but  with  a  similar  symp- 
tomatology; the  colics  were  undoubtedly  due  to  plugging  of  the 
bile-passages  with  the  tarry  material  with  which  the  gall-bladder 
is  ordinarily  filled.  In  nearly  all  these  cases  we  have,  before  open- 
ing and  draining  the  gall-bladder,  carefully  examined  the  pylorus, 
the  appendix,  and  the  right  kidney  to  complete  a  differential  diag- 


398  WLLLLLM   J.   MATO 

nosis.  In  all  the  cases  the  gall-bladder  was  evidently  the  affected 
organ,  its  walls  being  thickened  and  very  often  exceedingly  ad- 
herent to  neighboring  structures.  There  was  no  evidence  that 
stones  had  ever  been  present. 

I  have  recently  written  to  each  of  these  patients  to  find  out 
the  present  condition,  and  from  the  23  letters  received  19  replies; 
of  these,  15  write  that  they  are  well,  2  improved,  and  2  unimproved. 
Three  died  as  a  result  of  the  operation,  from  hepatargia.  This 
death-rate  alone  demonstrates  that  the  infection  is  often  more 
active  than  in  gall-stone  disease. 

A  few  words  in  regard  to  the  principles  underlying  operations 
upon  the  gall-bladder  and  bile-ducts.  The  most  important  ques- 
tion is  that  of  infection,  and  as  to  whether  it  is  acute  or  chronic, 
and  especially  whether  or  not  it  involves  the  liver-ducts. 

Every  gall-bladder  containing  calculi  can  be  looked  upon  as 
infected,  although  with  the  free  circulation  of  bile  and  nearly 
normal  gall-bladder  found  in  slumbering  stones  it  is  slight,  and 
the  "ideal"  operation — ^that  is,  complete  closure  of  the  gall- 
bladder and  abdominal  incision — may  be  performed;  but  it  will 
occasionally,  even  then,  lead  to  disaster — to  say  nothing  of  the 
danger  of  overlooking  stones — which  may  and  does  happen  to  the 
most  expert.  The  ideal  operation  has  been  performed  largely 
upon  these  latent  cases  found  during  other  operations,  and  the 
conclusions  dra^m  cannot  be  safely  applied  to  gall-stones  in  a 
state  of  activity,  which  of  itself  argues  an  infection  of  a  more 
acute  type.  Cholecystotomy  and  drainage  is  the  operation  of 
choice  in  these  cases.  Patients  suffering  from  active  gall-stones 
with  periods  of  latency,  in  a  fairly  normal  gall-bladder  with  patent 
ducts,  are  nearly  always  cured  by  this  method.  Drainage  is  con- 
tinued until  the  bile  is  normal.  This  is  a  safe  operation,  as  the 
gall-bladder  is  fastened  to  the  abdominal  incision,  the  fundus  is 
permanently  elevated,  and  gravity  drainage  through  the  cystic 
duct  is  even  better  than  in  the  normal  state.  Gall-bladders  with 
thickened  walls,  and  especially  if  the  cystic  duct  has  been  ob- 
structed, are  hable  to  give  trouble  after  cholecystotomy,  and,  if 
possible,  the  organ  should  be  removed.     If  the  liver-ducts  are 


STATUS    OF    SUUCiKUY    OF    (JALL-IlLADUKIt    AM)    111LK-DL(  TS       'JIM) 

entirely  free  from  iiivoivenieiit,  then,  and  only  llien,  sliouM  the 
cystic  duet  be  tied  and  the  pdl-hladder  excised  without  drainage 
of  the  bile  from  the  liver-ducts;  but  if  the  hepatic  ducts  are  in- 
volved, free  drainage  of  the  bile  to  the  surface  must  be  provided  for 
by  leaving  the  cystic  duct  open.  Kehr  says  that  the  hei)atic  ducts 
require  drainage  in  37  per  cent,  of  cases,  and,  with  increased  ex- 
perience, we  believe  that  this  is  not  too  high  a  percentage. 

It  was  in  the  management  of  such  cases  that  we  recommended 
the  removal  of  the  nmcous  membrane — the  peritoneal,  as  much  as 
may  be  of  the  muscular  coats  being  left.  The  cystic  duct  is  cut 
across  and  left  open  in  the  bottom  of  the  pouch,  the  outer  margins 
of  which  are  ])rought  to  the  surface  and  drained  in  the  same 
manner  as  after  cholecystotomy.  It  gives  all  the  advantage  of 
temporary  hepatic  drainage  with  the  permanent  benefits  of  chole- 
cystectomy. To  cut  the  gall-bladder  away,  leaving  the  cystic 
duct  open,  spouting  bile  into  the  abdominal  cavity,  requires  a 
quantity  of  drainage,  and  does  not  compare  in  ease  and  safety 
with  the  method  we  have  described  and  practised.  The  raucous 
membrane  of  the  fundus  of  the  gall-bladder  does  not  separate  easily, 
but  in  the  vicinity  of  the  cystic  duct  it  can  be  readily  removed. 
For  this  reason  we  usually  amputate  the  fundus  and  remove  the 
mucous  membrane  from  the  lower  portion.  We  can  recommend 
this  with  much  confidence,  as  in  a  considerable  experience  we  had 
no  deaths  and  no  relapses.  In  stones  in  the  common  duct  drainage 
of  the  hepatic  duct  is  essential.  This  usually  has  been  done  by 
suturing  the  common  duct  and  draining  through  the  gall-bladder 
by  cholecystotomy. 

W.  E.  B.  Davis  first  recommended  leaving  the  common  duct 
open  after  removing  stones,  for  drainage  of  the  hepatic  ducts,  and 
as  these  cases  are  usually  jaundiced  and  bad  subjects  for  operation^ 
this  time-saving  practice  has  often  proved  to  be  of  the  greatest 
value. 

In  49  choledochotomies  we  had  but  3  deaths,  and  the  method 
of  Davis,  in  whole  or  in  part,  has  been  the  one  of  choice,  the  gall- 
bladder being  also  drained  at  the  same  time. 

In  comparing  the  surgery  of  the  gall-bladder  with  that  of  the 


400  WILLIAM   J.    MAYO 

appendix,  this  essential  point  of  difference  exists :  in  removing  the 
appendix  every  effort  is  made  to  prevent  leakage  from  its  attach- 
ment to  the  cecum,  while  in  the  gall-bladder  the  necessity  of  thor- 
ough drainage  from  the  liver-ducts  out  of  the  external  incision  is, 
in  many  cases,  necessary  to  success.  Of  the  454  cases  up  to 
December  11,  1902,  upon  which  this  paper  is  based,  438  are  from 
the  records  of  St.  Mary's  Hospital  and  16  occurred  in  the  Minne- 
sota State  Hospitals  for  the  Insane. 


MALIGNANT  DISEASE  OF  THE  COMMON  BILE 

DUCT* 

WILLIAM  J.  MAYO 


Primary  carcinoma  of  the  common  duct  is  rare.  In  4578 
autopsies  Kelynack  found  8  cases  of  primary  cancer  of  the  gall- 
l)Iadder,  only  2  of  which  had  their  origin  in  the  duct.  Musser 
collected  100  cases  of  carcinoma  of  the  gall-bladder  and  18  of  the 
hile-ducts.  The  site  of  the  neoplasm  in  the  common  duct  is 
usually  either  at  the  juncture  of  the  hepatic  and  cystic  ducts  or 
near  its  duodenal  termination.  The  18  cases  collected  by  Musser 
showed  3  in  the  hepatic  duct  and  14  in  the  common  duct,  and  of 
the  latter,  9  were  at  or  near  the  papilla.  In  17  cases  of  cancer  of 
the  ducts  Rolleston  found  15  in  the  common  duct,  and  of  these  10 
were  at  or  near  the  papilla.  In  511  operations  upon  the  gall- 
bladder and  bile-passages  performed  in  St.  Mary's  Hospital  up  to 
March  21,  1903,  22  were  for  malignant  disease,  and  of  this  number 
it  was  thought  that  G  began  in  the  ducts.  In  several  cases  the 
exploration  did  not  reveal  the  exact  site  of  origin. 

As  to  the  etiology  of  carcinoma  of  the  common  duct,  there  is 
some  question.  It  must  be  conceded  that  gall-stones  are  the  most 
common  cause  of  cancer  of  the  gall-bladder.  In  Musser's  100  cases 
of  gall-bladder  carcinoma  69  contained  gall-stones  and  good  evi- 
dence that  calculi  had  at  one  time  been  present  in  the  majority  of 
the  remainder. 

Primary  cancer  of  the  gall-bladder  and  gall-stone  disease  are 
more  common  in  females  than  in  males,  and  in  about  the  same  pro- 
portion. This  is  not  true  of  duct  carcinoma.  Malignant  disease 
of  the  common  duct  is  equally  frequent  in  the  male  antl  female, 

*  Reprint  from  "  Xorlhwestern  Medicine,"  1903,  vol.  i,  No.  4. 
VOL.  I— ;2G  401 


402  WILLIAM   J.    MAYO 

which  does  not  favor  the  behef  that  gall-stones  are  the  cause  of  the 
malignant  process  in  the  duct. 

In  22  collected  cases  of  cancer  at  or  near  the  papilla  of  the  com- 
mon duct  Edes  found  gall-stones  in  but  4,  and  3  of  these  were  in  the 
gall-bladder.  In  36  cases  of  cancer  of  the  common  duct  Rolleston 
found  gall-stones  in  less  than  half.  The  extensive  experience  of 
Mayo  Robson,  however,  entitles  his  opinion  to  great  weight,  and 
he  states  his  belief  that  gall-stones  are  the  most  common  cause  of 
malignant  neoplasms  in  the  biliary  passages,  although  the  calculi 
have  not  remained  in  situ. 

The  histologic  variety  of  carcinoma  of  the  ducts  is  always  of  the 
columnar-cell  type,  although  Robson  says  that  secondary  degenera- 
tion of  papillomata  occurs.  Systemic  infection  is  rare ;  the  growth 
usually  progresses  by  contiguity,  and  sooner  or  later  the  lymph- 
glands  of  the  gastrohepatic  omentum  are  involved.  In  some  of  the 
cases  reported  the  growth  was  very  small  at  autopsy,  notably  the 
case  reported  by  Edes,  in  which  it  was  not  larger  than  a  bean,  even 
after  a  year  or  more  of  marked  symptoms.  Death  usually  occurs 
from  debility,  the  result  of  the  jaundice  and  infection  of  the  biliary 
ducts.  The  symptoms  are  not  distinctive,  and  the  diagnosis  can- 
not often  be  made.  The  chronic  jaundice  and  cachexia  are  not 
dissimilar  to  malignant  growths  of  the  head  of  the  pancreas,  and 
the  occurrence  of  glycosuria  and  fatty  stools  is  not  sufficiently 
common  in  the  latter  disease  to  aid  differentiation. 

In  primary  carcinoma  of  the  common  duct  pain  is  not  usually 
severe,  in  this  respect  differing  from  stones  in  the  same  situation; 
but  as  so  many  cases  have  at  one  time  had  stones,  the  diagnostic 
importance  of  the  pain  symptom  is  not  great.  There  is  usually 
no  tumor  present,  although,  not  infrequently,  the  distended  gall- 
bladder can  be  palpated  below  the  margin  of  the  liver,  but  not  the 
distinct  hard  tumor  of  cancer  of  the  gall-bladder.  The  question 
of  jaundice  is  an  important  one.  In  the  beginning  it  is  often  inter- 
mittent— very  much  like  stone  in  the  common  duct.  Occasionally 
this  will  lead  to  an  infection,  with  the  fever  and  chills  of  cholangitis. 
In  the  later  stages  jaundice  is  complete.  Maury  reports  a  recent 
case  with  the  typical  symptoms  of  Hanot  and  Rendu,  early  inter- 


MALIGNANT    DISEASE   OF   THE   COMMON    HII.K-DUCT  403 

mittent  jaundice,  insidious  onset,  and  diarrhea,  with,  later,  coni- 
plete  obstruction  of  the  common  duct.  An  ex[)Ioration  of  tlic  ducts 
in  doubtful  cases  is  the  only  way  a  positive  diagnosis  can  be  es- 
tablished. 

McBurney  first  called  attention  to  the  case  with  whicli  the  duo- 
denum could  'be  opened  for  the  pur])ose  of  removing  stones  im- 
pacted in  the  diverticulum  of  \'ater,  and  was  the  first  surgeon  to 
perform  the  operation.  We  have  several  times  successfully  opened 
the  duodenum  for  this  purpose,  and  a  large  number  of  such  opera- 
tions are  now  on  record.  Carle  strongly  urges  incision  of  the  duo- 
denum for  removal  of  stones  or  growths  from  the  duodenal  end  of 
the  common  duct,  and  cites  cases  in  which  stones  were  formed  in 
the  duct  which  later  might  give  rise  to  carcinoma.  Cancer  higher 
up  in  the  duct  would  necessitate  union  between  the  remaining  frag- 
ment of  the  duct  and  the  duodenum,  as  Halsted  succeeded  in  doing 
in  his  case.  As  a  palliation,  cholecystenterostomy  is  the  indicated 
procedure.  The  anastomosis  may  be  made  either  between  the  gall- 
bladder and  duodenum,  or,  if  the  latter  is  involved,  with  the  trans- 
verse colon  or  jejunum.  We  have  joined  the  gall-bladder  to  the 
transverse  colon  for  inoperable  obstruction  of  the  common  duct  or 
chronic  pancreatitis  five  times,  and  these  cases  did  fully  as  well  in 
every  respect  as  five  cases  in  which  the  duodenum  was  used  as  a 
receptacle  for  the  biliary  discharge.  One  case,  supposed  to  be 
malignant,  proved  not  to  be  so  by  living  in  good  health  six  years 
after  uniting  the  gall-bladder  and  colon.  Judging  from  our  own 
experience,  I  see  no  reason  why  the  transverse  colon  may  not  serve 
as  well  as  the  duodenum,  provided  the  latter,  more  favorable,  situa- 
tion is  not  practicable.  The  proximity  of  the  large  bowel  and  the 
nature  of  its  coats  render  anastomosis  with  the  gall-bladder  easy, 
and  in  the  palliation  of  malignant  disease  it  is,  perhaps,  almost  as 
good  for  the  purpose  as  the  duodenum.  In  the  original  work  of 
Winiwarter  it  was  the  chosen  method.  A  few  cases  of  enormous 
distention  of  the  common  duct  have  been  reported.  Robson 
details  an  instance  in  which  he  had  been  able  to  suture  such  a  cystic 
formation  to  the  surface  of  the  body.  Summers,  in  a  most  in- 
teresting case,  united  the  common  duct  to  the  duodenum,  with  a 


404  WILLIAM   J.    MAYO 

successful  result.     In  these  cases  the  obstruction  was,  however, 
non-malignant.     The  following  case  came  under  our  observation: 

Carcinoma,  Ampulla  of  Vater. — M.  K.,  female,  age  fifty-nine, 
German.     Admitted  to  St.  Mary's  Hospital  November  1,  1900. 

History. — For  many  years  patient  has  suffered  from  sudden 
attacks  of  pain  arising  in  the  epigastric  and  extending  to  the  right 
hypochondriac  region.  The  suffering  has  been  severe,  lasting  from 
two  to  six  hours,  and  ending  with  an  attack  of  vomiting  accom- 
panied by  prostration.  At  times  she  has  been  somewhat  jaundiced 
after  these  attacks.  About  one  year  ago  her  appetite  began  to  fail, 
and  distress  in  the  stomach  became  more  constant  but  less  severe. 
There  has  been  a  progressive  loss  of  weight — over  40  pounds  in  all. 
Family  and  personal  history  good. 

Examination. — Patient  somewhat  emaciated ;  there  was  a  marked 
cachexia  with  a  moderate  jaundice.  Pulse,  temperature,  and 
respiration  normal.  Liver  could  be  outlined  just  below  the  free 
margin  of  the  ribs;  gall-bladder  could  not  be  felt.  There  were 
tenderness  and  some  rigidity  of  the  muscles  in  this  region,  other- 
wise examination  negative.  Urine  had  a  trace  of  albumin  and 
much  bile.  Test-meal  developed  free  hydrochloric  acid,  and,  on 
distention  with  air,  the  outlines  of  the  stomach  were  found  to  be 
normal.  Stools  contained  traces  of  bile,  but  were  light  colored. 
The  history  was  clear  as  to  the  presence  of  gall-stones,  but  the 
patient  had  a  distinctly  cachectic  look. 

Diagnosis. — Either  gall-stones  in  the  common  duct  or  malig- 
nant disease. 

Operation  November  3,  1900.  Incision  through  the  right  rectus 
muscle.  Liver  somewhat  larger  than  normal;  gall-bladder  en- 
larged, containing  bile  mixed  with  ropy  mucus  and  a  single  non- 
faceted,  dark-colored  stone,  the  size  and  shape  of  a  small  pea. 
The  cystic  and  common  ducts  were  moderately  dilated,  but  no 
stone  nor  other  obstruction  could  be  detected  on  most  careful  ex- 
ploration. Gall-bladder  drained  to  the  surface  after  attaching  to 
the  parietal  peritoneum.  The  findings  were  unsatisfactory,  and 
did  not  account  for  the  condition  of  the  patient.  For  forty-eight 
hours  drainage  of  bile  was  free,  but  gradually  increased  in  quantity 
up  to  two  or  more  pints  a  day;  the  skin  became  greatly  irritated 
from  the  discharge,  and  examination  showed  that  a  large  part,  if 
not  all,  the  pancreatic  secretion  was  being  discharged,  with 
all  of  the  bile,  to  the  surface.  Stools  now  contained  bile.  A 
self-retaining  female  catheter  was  inserted  into  the  gall-bladder 


MALIGNANT    DISEASE   OF   THE   COMMON    BILE-DUCT  405 

through  the  fistulous  opening,  and  in  this  way  the  drainage  was 
directed  into  a  receptach*  without  <-«)nta(t  with  the  skin.  It  was 
evident  {\n\l  there  was  an  obstruction  which  liad  been  overlookecl 
at  tlie  duodenal  extremity  of  the  duct. 

Patient  was  in  a  very  feeble  condition,  and  on  November  'iOth 
was  allowed  to  return  home.  Even  with  the  continuous  drainage, 
she  imi)roved  somewhat.  The  jaundice  disappeared,  and  on  Jan- 
uary '-20,  1{)01,  she  was  readmitted  to  the  hosjjital.  On  January  31, 
1901,  an  incision  4  inches  in  length  was  made  to  the  inner  side  of 
the  fistula.  The  adhesions  were  separated,  and  the  common  duct 
and  duodenum  thoroughly  exposed.  At  the  extreme  end  of  the 
connnon  duct  a  hard  body  could  be  felt  through  the  wall  of  the 
duodenum,  the  size  of  a  filbert,  and  was  supposed  to  be  a  stone 
lodged  in  the  ampulla  of  ^'ater.  An  incision  was  made  2  inches  in 
length  in  the  anterior  wall  of  the  duodenum,  exposing  a  grayish- 
white  mass  which  was  strictly  localized  to  the  site  of  the  papilla  of 
the  common  duct.  Its  size  did  not  exceed  the  end  phalanx  of  the 
forefinger.  About  one-third  of  its  length  projected  into  the  free 
lumen  of  the  duodenum,  and  two-thirds  posterior  to  the  intestinal 
wall.  The  tumor  was  excised,  exposing  the  free  end  of  the  common 
duct.  The  removal  was  made  partly  with  a  knife  and  partly  with 
the  Pacpielin  cautery,  and  finally  the  whole  raw  surface  was  seared 
with  the  cautery.  The  common  duct  was  otherwise  free  from  ob- 
struction. The  incision  in  the  duodenum  was  sutured.  No  en- 
larged lymphatics  could  be  detected.  A  small  drainage  wick  was 
inserted  and  the  wound  closed.  The  attachment  of  the  gall- 
bladder to  the  skin  was  left  undisturbed.  The  discharge  from 
the  fistula  diminished  rapidly,  and  in  three  weeks  had  com- 
pletely ceased.  Stools  became  normal  in  color  and  the  gain  in 
weight  and  general  appearance  was  rapid.  For  nearly  a  year  and 
a  half  the  patient  remained  well.  About  the  middle  of  June,  lOO'-i, 
she  began  to  notice  some  pain  of  a  boring  character  in  the  epi- 
gastrium, soon  followed  by  jaundice,  which  slowly  progressed,  and 
on  July  7th  the  abdomen  was  opened  in  the  region  of  the  former 
incisions.  Gall-bladder  found  distended.  On  opening  the  duo- 
denum it  was  discovered  that  the  growth  had  returned  at  the  site 
of  former  operation.  Enlarged  lymphatics  were  present  and  also 
deep  attachments  to  the  pancreas.  Cholecystduodenostomy  was 
performed  with  the  Murphy  button,  with  recovery. 

The  specimen  was  examined  by  Le  Count,  and  Ids  report  is  as 
follows : 


406  WILLIAM   J.    iL^YO 

"The  tissue  is  from  the  duodenal  wall,  and  some  sections  show 
portions  of  Brunner's  glands.  Lieberkiihn's  glands  may  be  traced 
to  lower  depths  than  normal  through  a  very  inflammatory  mucosa 
that  contains  a  few  small  lymph-nodes  and  small  areas  of  hemor- 
rhage. Certain  of  these  glands  are  directly  continuous  vdih  groups 
of  epithelial  cells  that  lie  deeply  within  the  mucosa  and  the  mus- 
cular coats.  The  epithelium  in  these  invasions  are  altered  as 
follows:  they  lose  their  colunmar  shape,  become  possessed  of 
larger  and  more  deeply  stained  nuclei,  possess  karyokinetic  nuclei 
in  many  instances,  and  do  not  retain  their  characteristic  grouping, 
being,  instead,  arranged  in  disorderly  clumps  and  bunches  that 
vary  in  size ;  these  deeply  lying  collections  of  epithelial  cells  always 
possess  an  irregular  cavity  that  simulates  a  gland  of  the  simple 
tubular  type  or  a  gland-duct.  One  must  conclude  that  this  is  the 
tissue  from  a  cylindrocellular  carcinoma." 

So  far  as  the  writer  can  ascertain,  the  only  case  in  which  a 
carcinoma  of  the  common  duct  has  been  excised  previous  to  the 
one  herewith  reported  was  that  of  Wm.  S.  Halsted.  The  report 
of  the  case  was  pubhshed  in  the  "Boston  Medical  and  Surgical 
Journal,"  December  28,  1899,  No.  26,  vol.  cxh,  p.  645.  A  few 
cases  have  been  reported  since  then,  but  the  total  number  is  small. 


A  STUDY  OF  534  OPERATIONS  UPON  THE 
GALL-BLADDER  AND  BILP:-PASSA(;ES, 
WITH  TABULATED  REPORT  OF  547  OPER- 
ATED CASES* 

WILLIAM    J.    MAYO 


In  nature's  defense  against  infection  within  the  abdominal 
cavity  there  are  three  weak  situations — the  Fallopian  tube,  the 
appendix,  and  the  gall-bladder.  The  first  to  gain  an  accepted 
surgical  position  was  the  infective  lesions  of  the  tube.  The  ease 
of  diagnosis  and  the  remarkable  results  of  operative  interference 
contributed  largely  to  this  result.  The  appendix,  after  much  dis- 
cussion, has  also  reached  an  assured  place  in  surgery;  but  the  gall- 
bladder has  been  slow  to  receive  the  attention  from  the  medical 
profession  which  its  importance  deserves.  The  patient  is  usually 
along  in  years,  and  often,  by  reason  of  degenerative  lesions  or 
adipose  tissue,  a  poor  subject  for  operative  interference;  and, 
again,  death  does  not  frequently  come  with  that  tragic  sudden- 
ness which  oftentimes  marks  appendicitis. 

Like  the  appendix,  the  gall-bladder  is  a  dependent  organ  with 
a  limited  outlet,  connected,  although  less  directly,  with  the  in- 
testinal tract;  but,  fortunately,  at  a  point  in  which  the  micro- 
organisms normally  present  are  not  so  active.  Both  organs  are 
liable  to  stone  formation,  but  infections  of  the  gall-bladder  are 
usually  due  to  less  virulent  bacteria,  and  its  better  blood-supply 
and  distensibility  equalize  that  tension  which  is  so  fatal  a  char- 
acteristic of  the  inflamed  appendix.  Perforation  and  sudden 
death,  therefore,  are  less  frequent  in  diseases  of  the  gall-bladder. 

*  Presented  May  13,  1903,  at  the  Sixth  Triennial  Congress  of  American  Phy- 
sicians and  Surgeons.  Reprinted  from  "Boston  Med.  and  Surg.  Jour.,"  May  il, 
1903. 

407 


408  WILLIAM  J.    MAYO 

As  a  cause  of  chronic  distress  and  disability  in  adult  life,  how- 
ever, diseases  of  the  gall-bladder  nearly  equal  in  frequency  those 
of  the  appendix,  while  in  later  years  the  gall-bladder  undoubtedly 
takes  first  place.  The  inflammatory  affections  of  the  Fallopian 
tubes,  which  gave  such  an  impetus  to  pelvic  and  abdominal  sur- 
gery, have  dropped  to  third  place,  with  lesions  of  the  stomach  a 
close  competitor.  In  St.  Mary's  Hospital  in  1902  the  relative 
proportion  of  these  operations  was:  Appendix,  345;  gall-bladder, 
143;   ovaries  and  tubes,  98;   stomach,  77. 

The  534  operations  upon  the  gall-bladder  and  bile-passages 
which  form  the  basis  of  this  report  were  performed  upon  518  pa- 
tients, with  19  deaths — a  mortality  of  3.5  per  cent.  Of  the  total 
number,  510  were  for  gall-stone  disease,  with  a  mortality  of  3 
per  cent.  Considering  stones  in  the  gall-bladder  as  uncompli- 
cated, there  were  208  cases  with  2  deaths — a  mortality  of  less  than 
1  per  cent.  On  the  other  hand,  grouping  as  complicated  stones  in 
the  cystic  duct  stones  in  the  common  duct,  infections  with  and 
without  stones,  and  malignant  disease,  there  were  326  cases  with 
16  deaths — a  mortality  of  5  per  cent.  This  is  a  most  significant 
fact,  and  offers  a  strong  argument  in  favor  of  early  operation.  It 
has  been  said  that  of  the  5  to  10  per  cent,  of  adults  who  have  gall- 
stones, the  large  majority  do  not  have  symptoms.  I  am  convinced 
that  many  times  physicians  do  not  recognize  and  attribute  symp- 
toms really  present  to  their  proper  source  in  the  gall-bladder;  we 
too  often  make  an  indefinite  diagnosis  of  dyspepsia  or  indigestion. 

The  standard  of  measure  in  the  diagnosis  of  gall-stones  is  the 
"colic,"  yet  this  is  but  a  small  part  of  the  clinical  picture,  and  is 
readily  diagnosticated.  Not  so  the  chronic  distress  and  gastric 
disturbance  which  the  evolution  of  the  pathologic  process  so  often 
develops.  In  the  latter  case  the  victim  goes  the  round  of  the 
reputable  practitioners  of  medicine,  and  then,  unrelieved,  falls  into 
the  hands  of  the  charlatan  or  patent  medicine  vender,  until  com- 
plications develop  or  a  condition  of  encapsulation  is  established, 
subject  to  occasional  attacks  of  regional  inflammation. 

That  the  large  majority  of  adults  with  gall-stones  never  suffer 
is  true,  yet  these  stones  but  "slumber,"  with  the  possibility  of  a 


OPERATIONS  UPON  THK  C;ALL-HLAI)DP:R  AM)  HILE-PAR8AGE8    400 

I)aiiifiil  awakciiiii/^.  Once  ";uli\(',"  I  lie  cliaiicc  of  j>crmanently 
regaining  a  condilioii  of  "rrst"  is  nol  good,  altlioiigli  the  inlcrval 
may  last  for  years.  Uiuler  normal  (;onciitions  tlie  })il('  lias  hccii 
supposed  to  be  sterile;  but  it  has  been  demonstrated  that  if  col- 
lected in  sufficiently  large  (juantitics,  a  few  bacteria  can  be  de- 
tected, and,  as  shown  by  Lartigau,  it  is  possible  that  the  necessary 
attenuation  of  the  infective  agents  is  produced  by  passage  through 
the  liver,  and  that  stagnation  of  the  infected  bile  in  the  gall- 
bladder is  the  usual  cause  of  the  "stone-building  catarrh,"  rather 
than  an  ascending  inflammation  from  the  intestines  through  the 
ducts.  A  gall-bladder  containing  stones  is  always  infected,  and 
when  this  organ  once  becomes  restless  from  the  irritation  of  its 
host,  the  chance  of  a  complete  reconciliation  is  improbable.  In 
19  cases  we  have  found  and  removed  unsuspected  gall-stones 
during  an  abdominal  operation  performed  for  another  purpose, 
and  in  the  light  of  the  findings  an  inquiry  properly  directed  demon- 
strated that  the  majority  of  these  patients  had  suffered  at  times, 
but  that  the  trouble  was  attributed  to  another  cause.  In  some 
of  these  cases  marked  contraction  of  the  gall-bladder  or  dense  ad- 
hesions indicated  that  there  had  been  at  one  time  an  active  disease 
present.  The  truth  is  that  there  are  varying  degrees  of  gall-stone 
activity,  of  which  the  form  characterized  by  "colics"  is  the  most 
noticeable,  for  obvious  reasons.  Not  only  is  the  mortality  in  the 
uncomplicated  cases  low,  but  the  operation,  as  a  rule,  is  of  the 
simplest  character — opening  the  gall-bladder,  removal  of  the 
stones,  and  attachment  of  the  fundus  of  the  organ  to  the  abdominal 
wall,  with  temporary  drainage  of  the  bile  to  the  surface.  Chole- 
cystostomy  not  only  effectually  cures  the  condition,  but  by  per- 
manently elevating  the  fundus,  the  cystic  duct  is  brought  to  the 
bottom  of  the  cavity,  and  gravity  drainage  ensues  in  the  future. 
It  is  probable  that  even  in  these  cases  cholecystectomy  will  be  the 
indicated  operation  in  the  near  future,  as  this  operation  can  be 
performed  with  almost  equal  safety.  The  "ideal"  operation,  that 
is,  complete  closure  of  the  gall-bladder  incision,  has  been  success- 
ful in  many  cases  of  slumbering  gall-stones  accidentally  found 
during  an  abdominal  operation  performed  for  other  purposes.     This 


410  WILLIAM  J.    MAYO 

is  a  dangerous  practice  in  active  gall-stone  disease,  as  activity 
means  an  increased  infection.  As  long  as  the  stones  do  not 
become  lodged  either  in  the  pelvis  of  the  gall-bladder  (Hart- 
mann's  pouch)  or  in  the  cystic  duct,  the  usual  short  colic  is  the  chief 
symptom,  and  cholecystostomy  is  sufficient.  If  the  stones  are 
impacted  in  either  situation,  the  colic  is  replaced  by  a  constant 
distress,  less  acute  but  more  continuous.  The  gall-bladder  be- 
comes distended,  and  its  walls  infiltrated  with  inflammatory  prod- 
ucts. In  such  cases,  as  a  rule,  the  stones  can  be  dislodged  and 
brought  up  and  out  through  the  gall-bladder,  and  an  ordinary 
cholecystostomy  performed;  but  occasionally  an  incision  through 
the  wall  of  the  duct  is  necessary  for  relief  of  the  impaction,  followed 
by  suture  of  the  duct  and  cholecystostomy  or  ablation  of  the  organ 
itself.  Operation  in  183  cases  of  stones  impacted  in  the  pelvis  or 
in  the  cystic  duct  resulted  in  6  deaths — a  mortality  of  3.25  per 
cent.  This  included,  however,  a  number  of  cases  of  severe  in- 
fections. Should  the  walls  of  the  gall-bladder  have  undergone 
marked  changes,  or  angulation  and  stricture  of  the  cystic  duct, 
resulting  in  mucous  fistula,  seem  a  possible  outcome,  cholecystec- 
tomy is  more  certain  to  afford  permanent  relief.  If  the  cystic 
duct  is  completely  obstructed,  so  that  the  gall-bladder  contains  no 
bile,  it  is  a  simple  operation  to  detach  the  organ  from  the  liver  and 
ligate  with  catgut  at  the  base;  but  if  the  gall-bladder  participates 
in  the  biliary  circulation  in  spite  of  the  obstruction,  it  is  not  always 
wise  to  ligate  the  cystic  duct,  especially  if  there  is  a  cholangitis 
present.  Under  such  circumstances,  if  it  is  decided  to  remove  the 
organ,  the  cystic  duct  should  be  left  open  for  drainage  of  the  bile 
to  the  surface.  It  is  in  this  class  of  cases  that  we  have,  where 
possible,  removed  the  fundus  and  the  entire  mucous  membrane, 
the  peritoneum  and  outer  layers  of  the  base  of  the  gall-bladder 
being  retained  to  form  a  pouch  into  which  the  end  of  a  drainage- 
tube  can  be  securely  fastened  for  the  purpose  of  safely  conducting 
the  bile  to  the  surface.  In  75  cholecystectomies,  either  complete 
or  with  the  modifications  outlined,  there  were  but  2  deaths.  This 
does  not  include  23  cholecystectomies  made  in  the  course  of  other 
operations. 


OPERATIONS  UPON  THE  GALL-BLADDKU  AM)  HILE-FASSAGES    411 

Kehr,  Robson,  and  all  surgeons  of  large  experience  in  gall- 
stone surgery  unite  in  declaring  that  tliey  have  not  known  gall- 
stones to  reform  after  operation,  and  this  has  been  our  experience. 
In  our  early  work  it  sometimes  happened  that  stones  would  be 
discharged  from  the  fistula  subsequent  to  the  operation,  or  occa- 
sionally the  outer  opening  would  cicatrize  before  all  the  calculi  were 
discharged,  and  those  retained  gave  rise  to  future  colics,  requiring 
secondary  operations,  not  because  the  stones  had  reformed,  but 
because  the  primary  operation  had  been  incomplete. 

It  is  the  fond  hope  of  the  patient  that  the  stones  will  pass  down 
and  out  through  the  common  duct,  and  not  infrequently  this  is  the 
case,  but  there  are  usually  more  behind.  We  have  never  operated 
upon  a  patient  who  has  passed  calculi  that  we  have  not  found  more 
in  the  gall-bladder.  The  passing  of  a  calculus,  instead  of  being  a 
reason  for  delay,  is  an  indication  for  operation,  as  the  next  "  labor" 
may  miscarry  and  lodge  the  stone  in  the  common  duct,  in  which 
situation  the  results  of  operative  interference  are  no  longer  certain 
on  account  of  the  attendant  jaundice  and  infection  of  the  common 
and  hepatic  ducts. 

Surgery  of  the  common  duct  has  become  a  fairly  safe  operation, 
the  mortality  depending  more  upon  the  condition  of  the  patient 
than  upon  any  difficulties  in  the  technic.  This,  of  course,  has 
some  marked  exceptions.  Davis,  both  experimentally  and  clin- 
ically, called  attention  to  the  necessity  of  freely  draining  the  bile 
to  the  surface  after  common-duct  operation,  and  demonstrated 
that  suture  of  the  duct  was  usually  unnecessary  and  occasionally 
harmful.  This  saved  much  time  in  a  class  of  cases  with  general 
debility  from  jaundice  and  infections  of  the  ducts,  in  which  time 
is  an  element  of  great  value.  If  the  cystic  duct  is  open,  enabling 
the  bile  to  flow  outward  through  the  gall-bladder  to  the  surface  by 
means  of  cholecystostomy,  suture  of  the  common  duct  may  be 
harmless,  but  not  otherwise. 

To  Robson  we  owe  great  improvement  in  the  technic  of  this 
operation,  especially  the  sand-bag  under  the  back  at  the  level  of 
the  liver,  to  tilt  the  costal  margin  outward  and  upward  on  the  prin- 
( iple  of  a  reverse  Trendelenburg  position.     The  incision  of  Bevan 


412  WILLIAM   J,    ^L\YO 

through  the  abdominal  wall,  as  modified  by  Robson,  in  dispensing 
with  the  lower  angle  and  carrying  the  upper  limb  close  to  the  costal 
margin,  enables  one  to  draw  the  liver  downward  and  outward, 
and  straightens  the  angle  of  the  cystic  duct  at  the  common  duct. 
In  this  way  removal  of  common-duct  stones  is  rendered  easy.  In 
many  cases  the  common  duct  is  so  dilated  by  stones  impacted  in 
the  terminal  portion  that  the  finger  can  be  easily  introduced,  and 
by  aiding  the  extraction  with  counterpressure  with  the  other  hand 
over  the  duodenum,  the  stone  may  be  coaxed  backward  and  out 
of  the  duct  incision.  The  finger  can  be  used  in  the  same  way  in 
the  hepatic  ducts.  In  no  other  way  in  some  cases  can  one  be 
certain  the  ducts  are  free.  In  a  few  cases  incision  of  the  duodenum 
and  direct  extraction,  as  advised  by  McBurney,  may  be  necessary. 

We  had  two  such  cases  in  our  earlier  experience.  The  "ball- 
valve"  stone,  so  graphically  described  by  Fenger,  was  met  with 
9  times.  Kehr  has  extended  the  usefulness  of  hepatic  drainage 
by  direct  tubage  of  the  hepatic  duct,  and  has  shown  us  how  to  cure 
some  cases  heretofore  considered  hopeless.  Out  of  the  534  cases, 
we  had  58  of  stones  in  the  common  duct,  with  3  deaths — 5.5  per 
cent.  The  relative  proportion  of  common-duct  cases  was  11  per 
cent,  of  the  whole — considerably  less  than  in  either  the  Kehr  or 
Robson  series,  who  report  a  percentage  of  nearly  20  per  cent. 
Even  11  per  cent,  is  too  high.  Gall-stones  should,  in  the  large 
majority  of  instances,  be  diagnosticated,  and  the  patient  sent  to 
the  surgeon  before  common  duct  symptoms  clinch  the  diagnosis 
and  force  operation  upon  the  patient. 

Chronic  pancreatitis,  shown  by  enlargement  of  the  head  of  the 
pancreas,  was  met  with  in  connection  with  gall-stone  disease  18 
times.  In  6  of  these  patients  cholecystduodenostomy  was  per- 
formed and  all  recovered.  In  the  remaining  12  cases  no  special 
treatment  beyond  the  removal  of  the  gall-stones  and  establishment 
of  drainage  was  adopted.  One  case  of  acute  pancreatitis  and  fat 
necrosis,  due  to  a  cholecystitis  from  one  large  gall-stone  in  the 
gall-bladder,  recovered  after  operation,  as  did  one  subacute  hem- 
orrhagic cyst  of  the  pancreas  from  the  same  cause. 

It  has  been  noted  experimentally  that  high  grades  of  infection 


OPERATIONS  UPON  THE  GALL-Ur,.\I)I)KH   AM)   HILPI-PASSAGES     413 

seldom  cause  stones,  although  these  infections  are  most  liaMe  to 
occur  ill  j)aticnts  who  already  suffer  from  cahuli.  In  the  acutely 
infected  cases  gangrene  or  perforation  of  the  gall-l)ladder  may  occur. 
In  the  more  chronic  infections  of  this  type  the  symptoms  are  almost 
identical  with  gall-stones.  In  534  cases  we  had  27  of  this  chronic 
character,  with  3  deaths.  The  mortality  at  once  demonstrates 
tliat  the  infection  was  more  virulent  than  in  gall-stone  disease. 
The  deaths  were  usually  due  to  "hepatargia,"  or  cessation  of  liver 
function,  which  the  experimental  work  of  Adami  helps  us  to  appre- 
ciate. These  cases  of  chronic  cholecystitis  are  very  interesting 
because  of  the  liability  to  overlook  the  condition  at  operation,  on 
account  of  the  absence  of  gall-stones,  although  the  gall-bladder 
shows  evidences  of  trouble. 

In  the  benign  series  it  is  to  be  noted  that  16  cases  came  to 
secondary  operation,  14  were  cured  by  the  second  operation,  2 
required  several  operations  before  cure  resulted.  The  average 
stay  in  the  hospital  was  slightly  less  than  three  weeks,  the  attempt 
being  to  remove  all  the  stones  at  the  primary  operation  and  make 
the  drainage  more  efficient  by  accurate  placing  and  retention  with 
catgut  sutures,  which  are  absorbed  before  it  is  necessary  to  remove 
the  drains.  This  reduces  the  quantity  of  packing  to  a  minimum 
and  enables  better  closure  of  the  wound  without  marked  hernia 
liability.  The  sutures  closing  the  abdominal  incision  are  left  in 
place  two  weeks,  which  makes  it  quite  safe  to  allow  the  patient  to 
get  about  early — an  important  factor  in  the  recovery  of  old  people. 
If  the  patient  is  cholemic,  we  give  chlorid  of  calcium  as  a  prophy- 
lactic against  hemorrhage.  Otherwise  we  have  not  found  a  special 
preparatory  treatment  to  be  of  value  beyond  the  ordinary  prepa- 
ration for  laparotomy.  The  after-care  is  very  simple.  If  possible, 
the  bile  is  conducted  into  a  bottle,  and  the  drainage  packing  is  not 
disturbed  until  the  end  of  the  first  week,  and  after  removal  of  the 
drains,  repacking  is  rarely  necessary.  In  severe  cases  bile  drain- 
age to  the  surface  is  essential,  and  for  this  purpose  the  cystic  duct, 
if  unobstructed,  offers  an  easy  and  safe  avenue  of  escape  from  the 
hepatic  ducts.     In  I>ut  few  cases  have  we  found  direct  incision 


414  WILLIAM   J.    MAYO 

and  tubage  of  the  common  duct,  as  recommended  by  Kehr,  ad- 
vantageous. 

Malignant  disease  of  the  gall-bladder  and  bile-ducts  was  met 
with  24  times,  or  4  per  cent,  of  the  total  number  of  cases.  The 
proportion  was  about  4  times  in  the  gall-bladder  to  once  in  the 
ducts.  In  some  cases  the  exact  origin  could  not  be  determined 
by  a  reasonable  exploration.  Five  times  the  gall-bladder  was 
removed  for  cancer.  In  2  of  these  cases  a  considerable  portion 
of  the  liver  was  also  excised.  Three  patients  are  alive,  one  nearly 
two  years,  but,  unfortunately,  with  recent  recurrence  and  ob- 
structive jaundice.  In  one  case  a  carcinoma  involving  the  ter- 
minal end  of  the  common  duct  was  excised  by  the  duodenal  route; 
recurrence  after  one  and  one-half  years  necessitated  cholecyst- 
duodenostomy. 

As  the  presence  of  gall-stones  occurs  in  only  15  per  cent,  of 
secondary  cancers  of  the  gall-bladder  and  in  over  90  per  cent,  of 
primary  cancers,  we  must  conclude  that  they  are  the  chief  etio- 
logic  factors  in  the  production  of  mahgnant  disease  of  this  organ. 
In  nearly  all  our  cases  gall-stones  were  present,  and  a  clear  history 
of  active  trouble  could  be  elicited,  although  there  may  have  been 
years  of  quiet  between  the  cohcs  and  the  development  of  the  cancer. 
While  the  possibility  of  cancer  could  not  be  of  itseK  considered 
an  indication  for  the  removal  of  gall-stones,  it  is  worth  considering, 
as  about  1  case  in  25  coming  to  the  operating-table  in  this  series 
had  malignant  disease. 

The  usual  precancerous  condition  would  seem  to  be  a  gall- 
bladder with  thickened  walls,  due  to  chronic  infection  and  calculi. 
It  is  just  this  class  of  gall-bladders  which  are  now  being  subjected 
to  excision  rather  than  drainage,  and  it  is  probable  that  in  the 
future  many  cases  of  cancer  will  be  removed  in  an  early  stage  with 
permanent  cure. 

Palliative  operations  for  malignant  disease  of  the  gall-bladder 
and  bile-ducts  are  not  of  great  service.  In  a  few  cases  of  common- 
duct  obstructions  cholecystenterostomy  gives  relief  for  a  time,  and 
if  the  duodenum  cannot  be  easily  reached,  the  transverse  colon 
serves  as  well  for  the  purpose  of  anastomosis. 


OPERATIONS  UPON  TIIK  OALL-ULADDKIl  AM)  MILK- PASSAGES    415 

In  5  cholecystenterostomies  for  m.-ili^Mumt  disease  4  were 
attached  to  the  transverse  colon,  with  1  death,  and  in  1  to  the 
duodenum.  In  non-niah'gnant  disease  we  attach  to  the  duodenum, 
if  possible,  the  Murphy  button  being  used  in  all. 

A  statistical  table  is  attached  herewith: 

A  TABLE  OF  547  OPERATIONS  UPON  THE  GALL-BLADDER  AND  BILE- 
PASSAGES  (MORE  THAN  ONE  OPERATION  PERFORMED  AT 
ONE  TIME,  ONLY  THE  MAJOR  IS  TABULATED;. 
OCCLRRJNC;  IN  ST.  MARY'S  HOSPITAL  OF 
R0CHESTE1{,  MINN.,  FROM  JUNE  !24, 
1891,  TO  MAY  13,  1903 

St.  Mary's  Hospital  reports,  527;  Minnesota  State  Hospital  and  private  practice,  20. 

Operations  fob  Benign  Disease 

Total.  Recov'd.  Died. 

Cholecystostomy:    stones  in  gall-bladder,  cystic 

duct,  or  both' 299  296  8 

Cholecystostomy:  polypus  in  gall-bladder 1  1 

Cholecystostomy:    gall-bladder  stone  with  acute 

pancreatitis  and  fat  necrosis 1  1 

Cholecystostomy:  cholecystitis  with  and  without 

stones 51  46  5 

Choledochotomy:  stones  in  common  duct 59  56  S 

Cholecystectomy:  gall-stone  disease 56  55  1 

Cholecystectomy:  cholecystitis 9  8  1 

Cholecystectomy:  cyst  of  gall-bladder  containing 

10  quarts,  supposed  to  be  ovarian 1  1 

Cholecystenterostomy:    chronic  pancreatitis  and 

jaundice,  4  with  gall-stones,  1  without 5  5 

Perforation  of  calculus,  al)scess  and  general  peri- 
tonitis      2  .  .  2 

Division  of  adhesions 16  16 

Duodenocholedochotomy:    stone   in   ampulla   of 

Vater 1  1 

Exploratory:  negative 21  21 

522  507  15 

Operations  for  Malign.^nt  Dise.\se 

Total.  Recov'd.  Died. 

Cholecystectomy 4  3  1 

Cholecystostomy:   obstruction  common  duct.  ..  .     5  3  2 

Cholecystectomy  and  partial  hejiatcctomy:    can- 
cer of  the  gall-bladder 1  1 

Duodcnocholcdocliotomv:    cancer  in  ampulla  of 

Vater ' _ 1  1 

Cholecystenterostomy:   malignant  obstruction  of 

common  duct 4  3  1 

Exploratory:  inoperable  cancer 10 

Malignant,  total 25  11  4 

May  13,  1903 547  518  19 


SOME  CAUSES  OF   FAILURE  OF  OPERATION 
TO  CURE  GALL-STONE  DISEASE* 

WILLIAM    J.    MAYO 


Surgery  of  the  gall-bladder  and  bile-passages  is  one  of  the  most 
satisfactory  branches  of  our  art.  The  relief  following  operation 
is  perfect  and  rapid,  leaving  little  to  be  desired.  The  death-rate, 
taking  the  cases  as  they  come,  is  hardly  more  than  3  or  4  per  cent., 
and  in  uncompKcated  cases  less  than  1  per  cent.,  depending  to  a 
large  extent  on  the  condition  of  the  patient.  Including  all  causes 
of  failure  to  cure,  either  complete  or  partial,  and  such  late  sequelae 
as  adhesions  and  hernia,  the  number  of  instances  is  small.  In  580 
operations  upon  the  gall-bladder  and  bile-passages  we  had  but  17 
cases,  or  3  per  cent.,  which  required  a  secondary  operation.  Dur- 
ing this  period,  however,  we  have,  on  a  number  of  occasions,  oper- 
ated a  second  time  for  symptoms  arising  after  an  operation  per- 
formed elsewhere.  It  is  fair,  therefore,  to  presume  that  some  of 
our  cases  have,  unknown  to  us,  been  operated  upon  at  a  later 
period  by  other  surgeons,  and  that  failures  to  establish  a  complete 
cure  have  been  more  numerous  than  this  percentage  would  indi- 
cate. It  must  be  taken  into  consideration  also  that  many  pa- 
tients have  symptoms  referable  to  uncured  lesions  which  are  not 
sufficiently^  serious  to  demand  operation,  and  these  may  be  ac- 
counted as  partial  or  temporary  failure ;  but  looked  at  even  in  this 
light,  gall-stone  surgery  is  wonderfully  successful.  Practically  all 
the  patients  are  benefited,  and  few  would  exchange  their  post- 
operative for  their  previous  condition. 

Poor  results  usually  occurred  in  our  earlier  work,  and  meeting 

*Read  at  the  Thirty-fifth  Annual  Meeting  of  the  Minnesota  State  Medical 
Society  at  St.  Paul,  June  17, 1903.  Reprinted  from  the  "St.  Paul  Medical  Journal," 
August,  1903. 

416 


FAILURE    OF    OPERATION    TO    TURE    OALL-STONE    DISEASE      417 

with  such  cases  has  gradually  enabled  us  to  overcome  the  causes 
which  lead  to  the  suh.scc|uerit  tn)ul)k'.s.  Of  course,  in  rare  in- 
stances the  condition  of  the  patient  may  not  warrant  a  comjjlete 
procedure  at  one  operation,  and  a  second  operation  is  deliberately 
elected.  With  a  single  exception,  to  he  referred  to  later,  all  the 
cases  in  which  results  were  less  perfect  than  was  desirable  occurred 
in  complicated  cases,  and  it  can  be  laid  down  as  an  axiom  that  de- 
lay in  seeking  surgical  relief  was  the  direct  cause  of  the  complica- 
tions. It  is  the  experience  of  surgeons  generally  that  compli- 
cated cases  have  usually  had  symptoms  long  enough  to  have  made 
a  diagnosis  possible  before  the  development  of  serious  lesions,  and 
that  an  operation  at  that  time  would  have  been  safer  and  cure 
more  certain. 

I  would  call  attention  to  the  clinical  fact  that  a  small  number  of 
patients  who  have  had  a  cholecystostomy  performed  will  have  a 
colic  or  two  following  operation,  and  sometimes  the  colic  accom- 
panied by  transient  jaundice.  We  have  observed  this  most  often 
during  the  first  month  or  two  after  discharge  from  the  hospital. 
In  the  large  majority  of  instances  the  colics  do  not  recur  and  the 
patient  remains  well.  The  temporary  trouble  is  probably  due  to  a 
crippled  gall-bladder  becoming  filled,  and  by  reason  of  recent  ad- 
hesions not  emptying  properly,  so  that  a  single  spell  of  pain  shortly 
after  closure  of  the  fistula  does  not  indicate  a  second  operation 
unless  there  are  other  evidences  of  trouble. 

The  most  common  cause  of  later  symptoms  is  incomplete  re- 
moval of  stones.  Tait  advocated  cholecystostomy  and  drainage 
based  upon  the  frequency  of  overlooking  stones,  as  it  enabled 
spontaneous  discharge.  In  one  case  in  our  early  experience  55 
calculi  worked  out  of  the  fistula  during  the  first  two  weeks.  There 
is,  however,  little  excuse  for  leaving  stones  in  the  gall-bladder,  as 
by  using  the  finger  as  a  guide,  even  a  small  calculus  will  rarely  be 
overlooked. 

Stones  in  the  cystic  duct  frequently  escape  attention,  and  it 

was  only  after  several  such  misfortunes  that  we  began  to  exercise 

greater  care  in  exploring  the  cystic  duct.     The  parts  are  deeply 

situated,  and  as  these  patients  are  often  obese,  it  was  not  easy  to 

VOL.  I — 27 


418  WILLIAM   J.    MAYO 

locate  such  a  calculus  previous  to  the  development  of  the  Robson 
technic,  that  is,  the  sand-bag  under  the  back,  the  high  incision, 
and  dislocation  of  the  liver  downward  and  outward,  which  exposes 
the  cystic  and  common  ducts  perfectly.  In  most  of  these  cases 
cholecystectomy  is  indicated.  If  the  stone  completely  obstructs 
the  cystic  duct,  the  duct  and  cystic  vessels  are  caught  with  curved 
forceps  just  beneath  the  impacted  stone.  The  duct  is  then  cut 
across  and  the  gall-bladder  and  duct  with  the  stone  quickly  re- 
moved from  below  upward,  almost  by  traction  alone,  with  an 
occasional  division  of  some  firm  adhesion  to  the  liver.  Twice  we 
have  reoperated  upon  cases  in  which  the  gall-bladder  had  been 
removed  distal  to  the  stone,  leaving  it  in  the  duct  to  cause  future 
trouble.  This  is  more  apt  to  be  the  case  when  the  gall-bladder  is 
dissected  out  from  above  downward.  The  deep  field  is  obscured 
by  the  blood  running  downward,  and  the  same  vessels  are  cut  over 
and  over  again.  Stones  are  often  overlooked  in  the  common  duct, 
as  they  may  lie  quiescent  for  years.  The  jaundice  may  be  very 
slight,  and  in  some  cases  not  noticeable.  The  gall-bladder  in  the 
mean  time  may  become  obstructed  at  the  cystic  duct,  so  that  this 
organ  may  be  enlarged  and  cystic,  with  calculus  at  the  neck  and 
nothing  to  call  attention  to  the  common-duct  stone.  This  is  so 
contrary  to  the  usual  condition  of  contracted  gall-bladder  and 
open  cystic  duct  in  common-duct  stone  as  to  lead  to  error.  The 
ducts  should  be  explored  with  the  fingers  in  every  case  before  open- 
ing the  gall-bladder.  After  opening  the  gall-bladder  the  relief  of 
tension  prevents  moving  the  stone  in  the  dilated  duct,  and  escape 
of  the  cystic  contents  is  apt  to  soil  the  field.  If  the  gall-bladder  is 
distended,  it  is  well  to  explore  a  second  time  after  tapping,  but 
before  opening  the  gall-bladder  with  the  attendant  possibility  of 
infecting  the  deep  parts.  If  stones  are  found  in  the  common 
duct,  it  will  usually  be  suflSciently  dilated  to  introduce  the  finger 
into  the  duct  for  exploration.  In  many  cases  in  no  other  way  can 
we  be  sure  the  common  and  hepatic  ducts  are  clear. 

One  source  of  failure  of  cholecystostomy  to  cure  is  from  secon- 
dary obstruction  of  the  cystic  duct  preventing  free  drainage  of  the 
gall-bladder  down  through  the  passages.  This  may  eventuate  in 
a  mucous  fistula  or  repeated  attacks  of  colics  as  the  gall-bladder 


FAILURE    OF    OPERATION    TO    CURE    GALL-STONE    DISEASE      411) 

secretions  are  periodically  forced  through  the  stricturcd  duct. 
In  some  cases  the  gall-hhidder  will  distend  and  finally  rupture 
through  the  scar,  discharging  bile  and  mucus.  In  practically  all 
these  cases  the  cystic  duct  has  been  obstructed  by  stone,  causing 
ulceration,  the  healing  of  which  induces  a  stricture,  or  kinking  of 
the  channel  may  occur.  Other  things  being  equal,  it  is  better  to 
excise  the  gall-bladder  in  all  cases  in  which  the  cystic  duct  is  in- 
volved. In  this  way  we  have  of  late  eliminated  the  most  common 
cause  of  secondary  trouble. 

In  septic  cases  drainage  is  necessary  for  a  long  period  of  time, 
and  if  the  fistula  be  allowed  to  close  too  quickly,  severe  symptoms 
may  ensue.  On  two  occasions  we  have  had  to  reopen  and  re- 
establish drainage  in  septic  cholecystitis;  both  cases  were  colon 
infections.  This  is  less  liable  to  happen  in  ordinary  empyema  of 
the  gall-bladder,  in  which  a  fistula  will  usually  remain  until  ster- 
ilization has  been  accomplished  by  natural  processes.  In  colon 
infections  tubage  should  be  continued  until  the  bile  becomes 
sterile. 

Cancer  can  also  be  said  to  be  secondary  to  stone  formation, 
and  may  take  place  after  cholecystostomy  or,  being  present,  may 
be  mistaken  for  inflammatory  disease.  All  thick-walled  gall- 
bladders should  be  looked  upon  as  suspicious,  and  as  they  are 
functionally  useless,  cholecystectomy  should  be  done  rather  than 
cholecystostomy;  in  this  way  many  early  cancers  will  be  cured. 

Chronic  pancreatitis  may  exist  at  the  time  of  operation,  and 
to  obtain  a  good  result  drainage  should  be  long  continued.  We 
have  twice  allowed  the  fistula  after  cholecystostomy  to  heal  too 
quickly.  The  secondary  symptoms  were  marked  by  attacks  of 
slight  jaundice,  occasionally  fever  and  chills,  and  rather  persistent 
stomach  trouble.  At  the  second  operation  the  only  cause  found 
for  the  condition  lay  in  a  chronic  pancreatitis,  and  both  cases  were 
cured  by  cholecystenterostomy.  We  should  examine  every  case 
as  to  the  condition  of  the  pancreas  at  the  time  we  explore  the  ducts, 
and  if  this  disease  is  present,  either  drain  the  gall-bladder  for  a  long 
time  or  do  a  cholecystenterostomy  with  the  Murphy  button  in 
addition  to  removing  the  stones.  In  the  beginning  of  this  paper 
I  spoke  of  having  seen  only  one  uncomplicated  case  which  re- 


420  WILLIAM   J.   MAYO 

quired  a  secondary  operation.  This  was  a  cholecystostomy  with 
a  very  large  gall-bladder;  the  stones  were  easily  removed  and  the 
ducts  were  free.  For  weeks  after  operation  bile  escaped  occasion- 
ally from  the  fistula,  not  much,  but  troublesome.  On  dissecting 
out  the  gall-bladder  it  was  found  that  by  a  low  attachment  to  the 
abdominal  incision  this  viscus  had  formed  a  channel  along  which, 
in  certain  positions  of  the  body,  bile  would  gravitate  outward. 
After  cholecystostomy  the  gall-bladder  should  be  attached  as  high 
up  in  the  incision  as  is  convenient.  Persistent  biliary  fistula  us- 
ually means  obstruction  of  the  common  duct.  I  take  it  that  every 
one  understands  the  importance  of  not  attaching  the  gall-bladder 
to  the  skin.  In  the  early  days  persistent  bile  fistula  was  usually 
due  to  a  mucocutaneous  suture,  the  evils  of  which  obsolete  prac- 
tice I  do  not  need  to  point  out. 

Turning  in  the  margins  of  the  incision  in  the  gall-bladder  and 
drawing  a  purse-string  suture  closely  about  the  drainage-tube  in  a 
similar  manner  to  a  Kader  gastrostomy  enables  healing  of  the  fis- 
tula to  take  place  promptly.  There  are  two  rather  common  causes 
of  failure  to  effect  a  perfect  cure  which  can  not  always  be  avoided. 
Postoperative  adhesions  are  liable  to  cripple  the  movements  of  the 
viscera  in  this  neighborhood.  Adhesions  to  the  stomach  and  duo- 
denum are  the  most  annoying.  Secondary  separation  may  be 
necessary,  with  the  use  of  Cargile  membrane.  As  a  rule,  like  the 
pain  of  old  pleuritic  adhesions,  in  time  relief  comes  as  bands  stretch 
out.  We  make  it  a  rule  not  to  allow  gauze  drains  to  come  in  con- 
tact with  the  stomach  and  duodenum  on  account  of  the  develop- 
ment of  adhesions.  We  always  interpose  a  piece  of  rubber  tissue 
and  leave  it  from  six  to  eight  days,  until  the  adhesive  film  surround- 
ing the  drains  becomes  organized.  Hernia  following  operations 
for  gall-stone  disease  is  not  usually  troublesome,  but  long  incisions 
in  obese  people  may  give  rise  to  serious  hernial  protrusion  requiring 
secondary  operation.  If  practicable,  in  such  cases  we  now  make  a 
second  opening  outside  the  working  incision,  close  to  the  ribs. 
Through  this  the  drainage  material  may  be  brought  out  and  en- 
able us  carefully  to  close  the  full  length  of  the  original  incision. 
The  necessity  for  this  is  increased  if  the  opening  has  been  extended 
downward  for  the  purpose  of  removing  the  appendix. 


SOME  OBSERVATIONS  ON  THE  SURGERY  OF 
THE  COMMON  DUCT  OF  THE  LIVER* 

WILLIAM   J.    MAYO 


That  the  gall-bladder  is  infected  through  the  bile  in  the  large 
majority  of  cases,  and  not  by  way  of  the  common  duct  and  duo- 
denum, is  at  least  an  interesting  theory.  Undoubtedly  this  latter 
route  of  bacterial  invasion  takes  place,  especially  in  the  more 
serious  grades  of  infections,  and  often  without  stones. 

The  early  experiments,  which  showed  the  normal  bile  to  be 
sterile,  have  been  proved  untrue,  and  we  must  look  upon  the  bili- 
ary secretion  as  containing  a  few  bacteria  which  can  be  detected 
if  a  sufficiently  large  quantity  be  examined.  In  the  formation  of 
stones  the  necessary  attenuation  of  the  infective  agents  is  obtained 
by  passage  through  the  liver  under  conditions  which  have  proved 
most  difficult  to  duplicate  in  an  artificial  manner,  hence  the  few 
examples  of  true  stone  formation  which  have  followed  experi- 
mentation. The  result  is  usually  a  more  severe  and  non-calculous 
form  of  infection. 

A  gall-bladder  once  infected  remains  infected,  needing  only  a 
disturbing  element  to  reproduce  its  original  intensity.  Given  an 
infected  gall-bladder  containing  stones  which  cause  mechanical 
irritation,  and  we  have  the  most  favorable  conditions  for  frequent 
bacterial  excursions  into  the  common  duct,  and  should  this  be 
accompanied  by  calculi  which  fail  to  pass  the  duodenal  orifice,  we 
have  all  the  conditions  favorable  for  the  development  of  cholangi- 
tis, pancreatitis,  etc. 

At  least  90  per  cent,  of  all  the  diseases  of  the  common  duct 
upon  which  we  are  called  to  operate  arise  in  this  way. 

*Rcprinted  from  the  "Medical  Record,"  April  30,  1904. 
4:il 


422  WILLIAM  J.    MAYO 

The  primary  importance  of  the  gall-bladder  must  be  recognized 
in  the  etiology  of  these  infections,  and  operation  should  be  per- 
formed at  a  time  when  the  infection  and  stones  are  still  in  their 
originating  viscus. 

The  cystic  duct  and  its  patency  are  most  important  elements 
in  the  problem,  and  the  question  of  treatment  is  to  a  large  extent 
based  upon  its  condition.  If  the  cystic  duct  is  closed  mechanic- 
ally, either  by  stone,  kink,  or  stricture,  a  diseased  gall-bladder 
results,  which  is  better  out  than  in.  The  infection  has  confined  its 
ravages  to  the  organ  itself,  and  we  find  a  cystic  gall-bladder  with 
impacted  stones,  thick  walls,  and,  above  all,  with  an  obstructed 
cystic  duct.  Such  organs  are  functionless,  and  if  drained  and  left, 
they  will  be  a  possible  source  of  future  troubles,  among  which  may 
be  mentioned  reinfection,  mucous  fistula,  cancer,  or  colics  due  to 
failure  to  drain  its  secretions  down  through  the  common  duct. 
The  keynote  to  the  diagnosis  of  this  condition  is  found  in  the  fact 
that  the  gall-bladder  contains  no  bile.  Not  all  cystic  gall-bladders 
require  removal,  as  a  large  stone  in  the  pelvis  of  the  gall-bladder 
may  block  without  injury  to  the  duct — after  removal  of  the  stone, 
bile  at  once  appears. 

In  these  cases,  if  there  is  no  evidence  of  a  cholangitis,  there  is 
no  need  of  bile  drainage  to  the  surface,  and  the  duct  can  be  per- 
manently occluded  by  ligation.  Cholecystectomy  is  easily  per- 
formed from  below  upward;  the  cystic  duct  and  vessels  are  caught 
with  forceps;  a  second  forceps  on  the  gall-bladder  side  prevents 
leakage  and  enables  division  of  the  cystic  duct  and  vessels.  The 
gall-bladder  can  be  readily  separated  from  below  upward  without 
hemorrhage  or  trouble.  When  the  dissection  has  progressed  a 
short  distance,  the  forceps  on  the  deep  end  of  the  duct  and  cystic 
vessels  are  removed  after  ligation  with  catgut,  to  which  latter  a 
light  gauze  drain  is  attached  to  prevent  displacement.  This 
guard  against  leakage  should  always  be  taken. 

The  above  method  of  removal  enables  careful  ligation  of  the 
deep  parts  and  bloodless  separation  from  the  liver,  whereas  if  the 
gall-bladder  is  removed  from  above  downward,  the  same  vessels 
are  cut  over  and  over  again,  obscuring  the  deep  field  with  blood. 


SURGERY   OF   COMMON    DUCT    OF   THK    LIVER  423 

If  the  gall-bladder  contains  hile,  we  have  an  entirely  different 
condition  to  deal  with.  Free  communication  through  an  open 
cystic  duct  means  a  possible  infeetion  of  the  common  duct,  and  if 
the  infection  is  at  all  marked,  provision  must  be  made  for  bile 
drainage  to  the  surface.  This  can  be  accomplished  best  by  chole- 
cystostomy  and  draining  through  natural  channels.  Should  it  be 
deemed  wise  to  remove  the  gall-bladder  in  such  cases,  we  have 
practised  in  many  instances  amputation  of  the  fundus,  retaining 
the  base  to  form  a  pocket  from  which  the  mucous  membrane  is 
removed,  and  into  which  the  drainage-tube  can  be  securely  fastened 
to  the  cut  end  of  the  cystic  duct.  This  gives  temporary  bile 
drainage,  with  the  permanent  benefits  of  a  cholecystectomy. 

The  foregoing  procedure  is  also  very  useful  in  some  cases  of 
cholecystectomy  in  which  deep  adhesions  render  the  typical  opera- 
tion fraught  with  peril  to  the  liver,  duodenum,  and  deep  vessels. 
There  have  been  some  purely  theoretic  objections  advanced  to  this 
device,  and  it  is  not  ideal;  but  the  fact  remains  that  in  a  very  large 
number  of  cases  it  has  proved  both  safe  and  curative. 

Many  excellent  surgeons  believe  that  the  gall-bladder  should 
be  removed  in  every  case.  In  simple  cases  of  stones  with  latent 
infections  and  the  gall-bladder  in  good  condition,  no  harm  results 
from  ligation  of  the  cystic  duct,  even  if  patent,  which  is  shown  by 
the  presence  of  bile;  but  in  such  cases  cholecystostomy  gives  per- 
manent results,  which  fully  equal  cholecystectomy,  and  has  the 
advantage  of  less  manipulation.  It  also  leaves  the  gall-bladder, 
and  while  it  is  only  a  vestigial  remnant  and  probably  of  no  value, 
we  are  by  no  means  sure  that  it  should  be  sacrificed  unnecessarily. 
Time,  however,  may  prove  the  radical  course  the  proper  one  to 
pursue  in  all  cases.  In  our  experience,  cholecystectomy  has  had 
a  rapidly  growing  field  of  usefulness. 

We  hear  a  great  deal  about  hepaticus  drainage — that  is,  open- 
ing the  common  duct  and  introduction  of  a  tube  drain  into  the 
hepatic  duct.  We  should  not  forget  that  the  cystic  duct  is  an 
offshoot  of  the  common  duct,  and,  if  patent,  furnishes  natural 
drainage  to  the  surface.  In  many  cases,  however,  direct  tube 
drainage  from  the  main  ducts  is  life-saving.     Bile  drainage  through 


424  WILLIAM   J.   MAYO 

an  open  cystic  duct  amounts  to  identically  the  same  thing,  differ- 
ing only  in  degree,  and  the  question  to  be  decided  is  when  it  will 
not  be  sufficient.  We  have  usually  found  it  efficient,  and  unless 
the  common  duct  has  been  opened  for  the  removal  of  stones,  nat- 
ural drainage  by  way  of  the  cystic  duct  and  gall-bladder  furnishes 
results  which,  when  compared  with  indiscriminate  opening  and 
tubage  of  the  common  and  hepatic  ducts,  proves  the  former  method 
both  safe  and  easy,  and  greatly  lessens  the  disability. 

In  a  few  cases  the  cystic  duct  has  not  been  sufficient  for  this 
purpose.  We  have  then  removed  the  gall-bladder  and  split  the 
cystic  duct  down  into  the  common  duct  and  drained  the  deep  ducts. 

Stones  in  the  common  and  hepatic  ducts  require  removal  and 
drainage.  In  a  considerable  number  of  cases  stones  in  the  deep 
ducts  may  be  latent,  giving  no  symptoms,  and  especially  without 
jaundice.  Therefore  it  behooves  us  to  examine  carefully  the  ducts 
for  stones  in  all  cases,  even  if  we  have  no  special  reasons  to  antici- 
pate their  presence  beyond  the  fact  that  the  gall-bladder  contains 
calculi. 

For  all  operations  on  the  ducts  Robson's  technic  should  be  em- 
ployed :  the  sand-bag  under  the  back,  longitudinal  incision  of  the 
right  rectus  muscle,  with  division  of  its  inner  half  at  the  curved 
margin  of  the  costal  arch  up  to  the  ensiform  cartilage  (Bevan). 
In  two  of  our  cases,  at  the  extreme  upper  limit  of  this  incision  the 
anterior  mediastinum  was  opened,  allowing  air  to  suck  back 
and  forth.  This  incident  is  rather  startling,  and  makes  one  think 
the  pleura  may  have  been  accidentally  injured.  A  few  catgut 
sutures  close  the  rent  and  no  harm  results. 

If  the  common  duct  contains  stones,  one  of  them  is  seized  be- 
tween the  left  forefinger  and  thumb,  and,  using  the  stone  as  a 
guide  (Elliot),  two  lateral  mattress  sutures  are  placed,  leaving  a 
free  space  between  for  longitudinal  incision  of  the  duct  in  its 
visible  portion  between  the  cystic  duct  entrance  and  the  duo- 
denum. These  two  threads  with  long  ends  act  as  tractors,  and 
after  removal  of  stones  may  be  crossed  to  unite  the  duct  margins, 
always  leaving  a  little  chance  for  drainage  at  the  ends  of  the  in- 
cision.    In  the  majority  of  cases,  unless  the  cystic  duct  is  freely 


Fig.  41. — Cholecystectomy,  showing  clamps  applied  to  cystic  duct  and  cystic  vessels. 


^iC^ 


Fig.  42. — Cholecystectomy,  showing  cystic  duct  and  vessels  ligated.     Gall-bladder  paitially  separated 
and  sutured  in  position  to  cover  tie  exposed  liver  substance. 


SURGERY    OF   COMMON    DUCT   OF   TIIK    LIVER  4^3 

open  for  drainage  through  a  cholecystostomy,  it  is  Ixllcr  practice 
to  leave  the  incision  open,  either  completely  or  in  part,  and  use  the 
threads  to  fasten  the  drains  in  position.  Fixing  the  drains  prevents 
floating  hy  biliary  escape,  or  tlerangenient  hy  diaphragmatic 
action  exerted  upon  the  liver.  The  gauze  is  surrounded  by  rub- 
ber tissue  on  its  inner  and  lower  surface,  to  prevent  peritoneal  a<i- 
hesions. 

In  septic  cases  a  rubber  tube  M  to  |^  inch  in  diameter  is  cut 
fish-tailed  and  introduced  into  the  dilated  duct,  and  with  a  needle 
the  tube  is  secured  in  position  by  the  original  catgut  thread  on  each 
side.  The  outer  end  of  the  lube  can  be  placed  in  a  flattened  flask, 
which  is  held  in  the  dressing.  A  light  gauze  pack  is  placed  about 
the  tube  and  fastened  with  the  same  thread.  The  notch  cut  in 
each  side  of  the  deep  end  of  the  tube  permits  bile  to  pass  on  and 
out  through  the  papilla  at  any  time,  and  yet  furnishes  just  as 
complete  drainage. 

In  removing  stones  from  the  common  duct  the  finger  is  the 
only  reliable  guide,  and  without  it  one  cannot  be  sure  that  no 
calculi  have  been  missed.  The  bile-pressure  will  cause  an  ob- 
structed common  duct  to  distend  sufficiently  to  admit  a  medium 
forefinger  of  the  left  hand.  Stones  cannot  be  definitely  located 
by  probes  or  scoops.  I  have  repeatedly  removed  stones  until  the 
duct  appeared  to  be  free,  and  with  scoop  and  probe  failed  to  locate 
more,  yet  with  the  finger  I  have  located  further  calculi  with  ease. 
If  we  have  the  duct  open,  we  should  get  all  the  stones.  We  still 
occasionally  miss  stones  in  the  common  duct  because  the  symptoms 
were  not  sufficient  to  warrant  incising  it  and  palpation  proved 
inefficient;  but  in  all  cases  in  which  the  duct  is  dilated  and  jaun- 
dice is  present,  if  no  adequate  cause  for  the  condition  can  be  de- 
tected, we  should  open  and  explore. 

As  to  danger  of  hemorrhage  from  the  portal  vein  and  hepatic 
artery  in  a  well-conducted  operation  for  common-duct  stones: 
The  cystic  artery  fre(iuenlly  comes  off  from  the  sui)erior  pan- 
creaticoduodenal (Brewer),  and,  if  cut,  bleeds  sharply,  and  a 
large  vein  may  cross  the  duct,  antl,  if  wounded,  will  cause  the  field 


426  WILLIAM   J.    MAYO 

to  fill  with  blood,  leading  to  an  erroneous  belief  as  to  its  origin. 
These  vessels  are  easily  caught  and  tied. 

It  sometimes  happens  that  we  cannot  feel  stone,  yet  from  the 
symptoms  we  are  morally  certain  they  are  in  the  common  duct, 
while  the  parts  are  adherent,  with  the  anatomy  so  disturbed  that 
nothing,  not  even  the  duct  itseK,  can  be  recognized.  We  should 
find  and  open  the  common  duct  in  such  cases,  spht  the  gall-bladder 
from  top  to  bottom,  and  extend  the  incision  the  entire  length  of 
the  cystic  duct,  and  from  this  point  into  the  common  duct.  The 
adhesions  should  be  left  intact  to  act  as  barriers  to  infection. 
After  completing  the  common-duct  work,  the  cystic  duct  is  cut 
across  near  the  common  duct  and  the  gall-bladder  removed  from 
below  upward.  Or  in  some  cases  the  mucous  membrane  is  de- 
tached, as  previously  described.  Such  cases  are  in  this  way 
quickly  and  safely  disposed  of. 

In  this  connection  it  may  be  well  to  speak  of  chronic  pancreati- 
tis. We  have  had  26  cases.  In  some  of  these  calculi  were  present 
in  the  duct;  but  in  most  of  them  no  stones  were  found,  and  either 
cholecystostomy  or  cholecystenterostomy  was  performed.  All 
recovered.  Four  of  these  cases  have  already  returned  to  us  with 
renewal  of  previous  symptoms.  In  each  instance  no  stones  were 
detected  by  palpation  at  the  first  operation,  and  in  only  one  at  the 
second,  seven  months  to  a  year  after  the  first,  yet  upon  opening 
the  common  duct  and  exploring  with  the  finger,  a  small  stone  was 
found  in  the  ampulla  in  each  case.  The  head  of  the  pancreas  at 
the  second  operation  was  much  reduced  from  its  former  size.  In 
two  cases  since  that  time,  of  apparently  typical  chronic  pancreati- 
tis, a  small  stone  has  been  removed  from  the  diverticulum  of  Vater, 
and  in  none  of  these  cases  could  the  stone  be  discovered  by  palpa- 
tion, probing  through  the  incised  duct,  etc.  It  amounts  to  this, 
that  before  one  can  be  sure  that  chronic  pancreatitis  and  nothing 
else  causes  the  common-duct  obstruction,  one  must  open  the 
common  duct  and  explore  with  the  finger.  I  do  not  say  that  this 
is  true  of  all  cases  of  common-duct  obstruction  from  interstitial 
pancreatitis,  as  we  have  had  a  number  of  typical  examples  shown 
by  enlargement  of  the  head  of  the  organ,  jaundice,  etc.     The 


I'ig.  4,5. — Choli'iliKiioliirny.  sluiwin;,'  mclliDil  of  pliiciiiK  workinj;  sutures  in  ciimnmn  duct 


SUUGEUY    OF    COMMON    DLCT    Ol'    TllK    Ll\  lOU  4'-27 

preatly  enlarged  hojul  of  the  pancreas,  with  its  hard  luxhiles  in  the 
above  cases,  prevented  anything  approaching  accurate  palpation 
of  the  ampulla  in  which  the  stones  were  contained. 

It  was  interesting  to  note  that  in  the  two  cases  of  cholecyst- 
duodenostoniy  the  fistula  had  conii)leteIy  closed  in  from  six  months 
to  a  year.  The  movable  stone  permitted  escape  of  l)ile  at  intervals 
by  the  duodenal  end,  and  nature  promptly  closed  the  unnecessary 
opening.  On  the  contrary,  experience  in  a  number  of  cases  in 
which  the  obstruction  had  been  permanent  showed  a  patulous 
opening  after  years  had  elapsed. 

In  operating  on  the  common  duct  we  have  frequently  found  the 
small,  flattened,  and  dark-colored  (disk-shaped)  stones  originating 
in  the  hepatic  ducts,  but  invariably  there  has  been  a  larger  stone 
at  the  papilla,  thus  showing  that  an  obstruction  to  free  drainage, 
sufficient  to  cause  dilatation  of  the  ducts,  with  the  presence  of 
infected  bile,  causes  conditions  favorable  to  the  formation  of  duct 
stones,  but  always  secondary  to  an  original  blocking  stone  derived 
from  the  gall-bladder.  It  is  possible  that  duct  stones  may  arise 
primarily,  but  the  writer  has  not  personally  observed  such  a  case. 

The  reparative  power  of  the  common  duct  is  not  exceeded  by 
any  mucus-lined  channel  in  the  human  body.  One  not  infrequently 
encounters  cases  in  which  this  channel  after  operation  looks  very 
badly,  with  widely  separated  and  ragged  walls,  and  one  fears  that 
union  will  not  take  place,  yet  healing  almost  invariably  occurs, 
whether  the  duct  is  sutured  or  not.  During  1904  the  following 
3  cases,  illustrating  the  reparative  power  of  the  common  duct, 
occurred  in  St.  Mary's  Hospital: 

The  first  was  a  female  aged  twenty-two  years,  with  acute  in- 
fectious cholecystitis  and  cholangitis  and  with  stones  in  gall- 
bladder. In  emptying  the  gall-liladder  much  putty-like  material 
was  forced  into  the  deep  ducts.  To  enable  removal  of  this  sub- 
stance and  proper  drainage,  it  was  necessary  to  split  the  hepatic 
and  common  ducts  from  the  liver  to  the  shelter  of  the  duodenum; 
the  gall-bladder  was  also  removed.  The  margins  of  the  common 
duct  were  approximated  in  three  places  by  catgut  sutures,  the 
balance  being  left  open  for  drainage.  Patient  left  the  hospital  in 
twenty  days  with  a  healed  wound;  no  bile  was  discharged  after 
fourteen  days. 


428  ■WILLIAJM   J.    M-^YO 

The  second  patient  was  a  female  of  thirty-four  years.  In  re- 
moving a  gall-bladder  which  was  adherent  the  common  duct  was 
completely  severed  and  the  ends  separated  to  such  an  extent  that 
it  was  difficult  to  locate  the  distal  fragment.  The  proximal  end 
was  made  manifest  by  escape  of  bile.  The  severed  duct  was 
sutured  end  to  end  in  three-fourths  of  its  circumference  with  in- 
terrupted fine  catgut  sutures,  through  all  the  coats,  but  avoiding 
the  mucous  membrane  except  at  its  margin.  The  sheath  was 
treated  in  a  similar  manner.  It  was  not  possible  to  introduce 
more  than  five  or  six  sutures  in  all.  One-fourth  of  the  severed 
duct  was  left  open,  to  avoid  tension  and  secure  free  drainage. 
Bile  ceased  escaping  from  the  wound  on  the  sixteenth  day,  and 
the  patient  left  the  hospital  on  the  twenty-second  day  after  opera- 
tion. 

The  third  case  was  most  interesting.  A  female,  fifty-years  of 
age,  with  stones  in  gall-bladder  and  common  duct.  Gall-bladder 
malignant,  involving  cystic  duct  and  extending  lateraUy  upon 
common  duct.  Gall-bladder,  cystic  duct,  and  one  inch  of  com- 
mon duct  excised.  The  duodenum  and  head  of  pancreas  were 
liberated  by  incising  the  peritoneum  and  loosening  the  cellular 
attachments.  This  enabled  the  distal  end  of  common  duct,  which 
barely  projected  beyond  the  duodenal  shelter,  to  be  brought  to 
the  short  end  of  the  hepatic  duct.  The  duodenum  was  secured  in 
this  situation  by  sutures  posteriorly.  The  common  duct,  which 
was  dilated  to  the  size  of  a  lead-pencil,  was  sutured  as  in  the  case 
just  described.  One-fourth  was  left  open  for  drainage.  This 
patient  was  discharged  in  nineteen  days  with  a  healed  wound. 
She  remained  well  for  seven  months,  but  now  has  return  of  the 
malignant  disease,  shown  by  nodular  tumors  of  the  liver. 

In  two  additional  cases  the  common  duct  was  excised  for  maHg- 
nant  disease.  In  the  first  the  proximal  end  of  the  duct  was  united 
to  the  duodenum  by  a  new  opening.  The  third,  a  mahgnant 
tumor  of  the  common  duct,  was  excised,  with  end-to-end  suture. 
Death  followed  from  shock. 

In  remo\dng  stones  impacted  in  the  duodenal  end  of  the  com- 
mon duct  great  difficulty  may  be  encountered,  and  in  3  of  our 
cases  it  became  necessary  to  open  the  duodenum  (McBurney)  for 
the  purpose  of  extracting  the  stone.  It  was  only  by  means  of 
this  double  operation  that  the  duct  could  be  properly  cleared. 
The  duodenum  was  sutured,  and  the  common  duct  drained  in  the 


SURGERY    OF    COMMON    DUCT    OF    TIIK    LI\'KU  4'-29 

usual  uianncr.  lu  a  fourLli  (.asc  Llie  duodcnuiu  was  opt'iied  ior 
the  removal  of  a  cancer  of  the  ampulla  and  papilla.  All  of  these 
cases  recovered.  I  caiitioL  too  strongly  urt,'e  the  complete  re- 
moval of  all  stones  at  one  time  if  the  patient  can  hear  the  ojjcra- 
tion,  and  in  our  experience  it  has  been  safer  than  half-way  mea- 
sures, followed  l)y  unavailing  irrigations,  probing,  etc.  In  the 
large  majority  of  cases  a  secondary  operation  of  greater  magnitude 
than  the  first  was  necessary. 

Cholecystenterostomy,  while  not  an  operation  upon  the  com- 
mon duct,  is  indicated  by  disease  of  this  channel  and  may  be  classed 
with  it.  We  liave  resorted  to  it  only  for  benign  but  inoperable  ob- 
structions and  malignant  disease.  The  bowel  selected  should  be 
the  duodenum,  but  in  5  cases  this  was  impossible,  and  the  anas- 
tomosis was  made  to  the  transverse  colon  with  the  Murphy  button. 
Theoretically,  this  seems  a  dangerous  practice,  but  in  every  case 
the  result  was  just  as  satisfactory  as  when  the  duodenum  was  used. 
There  were  no  late  infections  of  the  bile-tract  from  colonic  bacteria, 
and  one  patient  lived  six  years,  dying  from  an  independent  dis- 
ease. A  second  is  alive  and  well  at  the  present  time,  four  years 
later. 

It  is  usually  possible  to  attach  to  the  duodenum,  but  until 
further  experience  has  shown  that  it  is  harmful  we  will,  in  the  few 
cases  necessary,  use  the  transverse  colon  rather  than  the  stomach 
(Kehr)  or  a  loop  of  jejunum  (Mikulicz)  for  this  purpose,  especially 
in  malignant  disease. 

Appended  will  be  found  a  table  of  107  operations  upon  the 
common  duct  which  occurred  in  7'"28  operations  upon  the  gall- 
bladder and  bile-passages  operated  upon  by  Charles  H.  and  Wil- 
liam J.  Mayo. 

Benign  Total.  Recovered.  Dead. 

Choledochotomy  for  stones  in  common  duct ....   83  75  8 

Duodcnocholedochotomy,  stones  in  ampulla  ....     3  3 

Cholecystenterostomy 6  6 

9i  84  8 
Cancer 

Duodcnocholedochotomy,  tumor  papilla 1  1 

Cholecystenterostomy 7  6  1 

Cholecystostomy,  tvnuor  common  duct 5  8  £ 

Common-duct  resection  for  tumor 4  1  1 

15  11  4 


A  REVIEW  OF  1000  OPERATIONS  FOR  GALL- 
STONE DISEASE,  WITH  SPECIAL  REF- 
ERENCE TO  THE  MORTALITY* 

WILLIAM    J.   AND    CHARLES    H.    MAYO 


From  June  24,  1891,  to  December  1,  1904,  1000  operations 
were  performed  upon  the  gall-bladder  and  bile-passages,  with  50 
deaths  (5  per  cent.)-  About  95  per  cent,  of  the  cases  were  oper- 
ated upon  in  our  clinic  in  St.  Mary's  Hospital  and  under  nearly 
identical  conditions. 

In  this  rapidly  growing  field  of  surgery  there  have  necessarily 
been  many  changes  in  technic,  and  for  such  changes  and  improve- 
ments we  are  greatly  indebted  to  the  literature  of  the  subject. 

A  study  of  mortality  must  be  based  upon  some  definite  plan, 
but  so  far  as  investigators  have  been  able  to  determine,  there  is  no 
settled  method  upon  which  a  correct  estimate  of  the  death-rate 
can  be  compiled  in  any  series  of  operations. 

What  are  we  to  understand  by  a  mortality  of  a  certain  per- 
centage? Some  operators  say  that  if  a  patient  dies  as  a  result  of 
the  operation,  the  death  should  be  counted;  whereas  if  the  opera- 
tion failed  and  the  patient  continued  to  live  for  a  time,  then  died 
from  the  disease  or  a  complication,  it  should  not  be  charged  to  the 
operation.  The  defect  in  this  method  of  computation  is  that  it 
allows  a  large  degree  of  personal  equation,  and  the  same  statistics 
may  be  made  to  look  very  well  or  very  bad  as  the  critic  is  preju- 
diced for  or  against  the  operation.  One  prominent  surgeon  de- 
clares that  the  death  of  a  patient  from  any  cause  within  fourteen 
days  should  be  attributed  to  the  operation,  and  after  that  time 
it  is  a  question  to  be  settled  by  the  judgment  of  the  surgeon. 

*  Reprinted  from  "Amer.  Jour.  Med.  Sci.,"  March,  1905. 
430 


OPERATIONS    FOR    (;ALL-ST()NK    DISEASE  431 

In  our  Sfrics  of  cases  \\v  have  taken  the  \  iew  of  the  ia\iiiari,  thai 
if  the  patient  goes  into  the  hosj)ital  aM\-e  ami  comes  out  dead,  the 
death  resulted  from  or  in  spite  of  the  operation.  It  is  to  he  under- 
stood, therefore,  that  in  estimating  the  death-rate  we  have  charged 
as  a  death  from  operation  every  patient  who  died  in  the  hospital, 
without  regard  to  cause  of  death  or  the  time  which  elapsed  between 
the  operation  and  the  fatal  issue.  It  includes  patients  dying  as 
long  as  three  months  after  operation  and  from  intercurrent  disea.se 
or  accidental  cause,  such  as  apoplexy,  pneumonia,  heart  di.sease, 
chronic  nephritis,  etc.  A  percentage  of  the  deaths  could  be  fairly 
excluded,  but  since  our  object  is  to  show  the  relative  curability  of 
gall-stone  disease  rather  than  good  statistics,  we  have  adopted  the 
above  method,  as  it  is  at  least  unprejudiced.  These  statistics 
undoubtedly  exaggerate  the  dangers  of  operation,  particularly  of 
common-duct  disease,  where  long-continued  infections  of  the  bile- 
passages  have  resulted  in  blood  changes,  causing  death  at  a  late 
period.  But  they  also  illustrate  the  dangers  of  delay  and  the 
resulting  complications  which  operation  may  fail  to  relieve. 

In  the  1000  operations  there  were  50  deaths  in  the  hospital, 
or  an  average  death-rate  of  5  per  cent.  In  the  series  classed  benign 
there  were  960  cases,  with  a  mortality  of  4.27  per  cent.  For 
malignant  disease  there  were  9  deaths  in  40  operations,  which  gives 
a  mortality  slightly  in  excess  of  22  per  cent. 

Where  the  disease  was  limited  to  the  gall-bladder,  including  all 
non-perforating  infections,  the  mortality  was  2.44  per  cent.;  573 
cholecystostomies — mortality,  2.46  per  cent.;  186  cholecystec- 
tomies— mortality,  4.3  per  cent.  This  does  not  include  101  chole- 
cystostomies and  44  cholecystectomies  performed  as  part  of  a 
common-duct  operation.  We  have  followed  the  rule  of  counting 
as  one  operation  all  the  different  procedures  done  through  a  single 
incision.  The  major  or  more  serious  are  classified;  the  others  are 
considered  secondary  and  appear  only  in  the  record  of  the  patient. 

Of  the  common-duct  operations,  there  were  137  benign,  with 
16  deaths — 11.7  per  cent.  This  gives  a  heavy  mortality,  but,  as 
already  pointed  out,  it  is  really  a  death-rate  of  operation  and  dis- 
ease, and  means  that  7  per  cent,  failed  to  recover  from  the  direct 


432  WILLIAM  J.    AND    CHARLES   H.    MAYO 

results  of  the  operation — that  is,  died  within  a  few  days;  while  4 
per  cent,  recovered  from  the  operation,  but  did  not  regain  sufficient 
strength  to  leave  the  hospital.  Many  patients  operated  were  in  a 
desperate  condition  from  prolonged  icterus,  anemia,  etc.  No  pa- 
tients were  refused  operation  if  they  so  elected  after  a  fair  statement 
of  the  facts.  Operations  for  malignant  disease  are  discouraging: 
40  operations,  with  9  deaths  in  the  hospital,  and  of  those  that  re- 
covered, comparatively  few  received  sufficient  palliation  to  repay 
the  immediate  risk,  suffering,  and  expense.  Two  cases,  however, 
can  be  considered  favorable  as  to  cure:  both  were  instances  of 
early  carcinoma  of  the  gall-bladder.  In  a  few  patients  a  thick- 
walled  and  functionally  useless  gall-bladder  was  removed,  and 
examination  showed  malignant  involvement,  and  in  the  two  cases 
referred  to  no  return  has  as  yet  taken  place  after  more  than  two 
years.  We  have  recently  had  two  cases  of  a  like  character,  but  it 
is  too  early  to  consider  them  as  "probably  cured." 

Next  to  malignancy  and  acute  perforative  infections  of  the 
gall-bladder  and  pancreas,  the  most  serious  thing  that  can  happen 
in  gall-stone  disease  is  involvement  of  the  common  duct  of  the 
liver. 

Contrast  a  mortality  of  2.44  per  cent,  in  820  cases  where  the 
disease  was  confined  to  the  gall-bladder  with  11.7  per  cent,  in  137 
cases  where  the  common  duct  is  involved. 

It  would  exceed  the  limits  of  this  paper  to  go  into  the  details 
as  to  the  various  operations  performed,  and  we  will  confine  our- 
selves to  a  short  discussion  of  the  mortality  in  the  benign  group  of 
cases  and  a  comparison  of  results  after  the  three  most  common 
operative  procedures,  cholecystostomy,  cholecystectomy,  and 
choledochotomy. 

It  can  be  fairly  stated  that  the  average  mortality  of  operations 
for  diseases  confined  to  the  gall-bladder  is  not  greater  than  for 
appendicitis  in  patients  of  the  same  age  and  condition  of  health. 
Gall-stone  disease  is  most  frequent  in  people  of  advanced  years — 
often  obese  and  not  infrequently  the  victim  of  some  degenerative 
lesion  of  vital  organs.     One  cannot  directly  contrast  such  cases 


OPERATIONS  I'oit  (;all-stone  disease  433 

willi  disease  of  the  appendix,  wliicli  is  hy  far  more  coniinon  in 
younger  and  more  rol)Ust  subjects. 

('holecjisto.stoinii. — Of  these,  there  were  573  (exclusive  of  101 
in  connection  with  common-duct  operations),  with  14  deaths — a 
mortahty  of  2.4C  per  cent.  This  includes  most  of  the  acute  in- 
fections with  localized  peritonitis.  At  least  one-third  of  these 
deaths  were  from  purely  accidental  causes  that  referred  to  the 
general  condition  of  the  patient.  The  mortality  of  cholecystos- 
tomy  in  simple  gall-stone  disease  in  otherwise  normal  individuals 
was  less  than  1  per  cent.  In  186  cholecystectomies  (exclusive  of 
36  common-duct  cases)  the  mortality  was  4.3  per  cent.,  or  nearly 
twice  that  of  cholecystostomies.  It  may  be  urged  that  this  latter 
operation  was  elected  in  the  more  severe  cases,  and  to  a  certain 
extent  this  is  true,  but  not  wholly  so,  since  the  more  dangerous 
acute  infections  were  nearly  always  drained  by  cholecystostomy. 
Inasmuch  as  in  not  a  single  instance  did  stones  reform  in  the  gall- 
bladder, cholecystostomy  must  be  considered  the  safe  operation, 
cholecystectomy  being  reserved  for  certain  cases  in  which  cholecys- 
tostomy may  be  expected  to  furnish  a  partial  or  complete  failure. 
Other  things  being  equal,  all  cystic  gall-bladders  should  be  re- 
moved, and  especially  when  a  stone  is  impacted  in  the  cystic  duct, 
as  not  infrequently  a  stricture  may  follow  removal,  interfering 
with  the  escape  into  the  common  duct  of  the  normal  secretions  of 
the  mucous  membrane,  thus  giving  rise  to  colics  or  external  mu- 
cous fistula.  As  a  rule,  gall-bladders  which  are  found  to  contain 
bile  at  the  time  of  operation  may  be  drained,  as  if  bile  can  get 
through  the  cystic  duct  mucous  secretion  will  escape.  If  the 
cystic  duct  should  be  considerably  injured  during  removal  of  the 
calculus  and  there  is  a  doubt  as  to  the  future  permeability,  the 
gall-bladder  should,  of  course,  be  removed.  Again,  gall-bladders 
which  are  suspiciously  thick  and  hard  should  be  excised,  as  in  this 
way  early  malignancy  may  occasionally  be  removed,  as  shown  in 
the  two  cases  referred  to  above. 

In  most  cases  of  chronic  cholecystitis  without  stones  the  gall- 
bladder should  be  removed.  The  presence  of  gall-stones  gives 
rise  to  irritation,  and  their  removal,  with  subsequent  drainage  by 

VOL.  I — 28 


434  WILLIAM   J.    AND    CHARLES   H.    MAYO 

cholecystostomy,  maj^  be  expected  to  leave  a  harmless  organ,  but 
an  infection  which  continues  without  the  aid  of  foreign  bodies  calls 
for  a  more  radical  operation. 

We  must  not  be  too  ready  to  diagnosticate  cholecystitis  with- 
out stones  on  operation,  or  we  may  cover  a  mistake  in  diagnosis 
and  send  home  an  unrelieved  patient  with  an  unnecessary  opera- 
tion. Before  a  diagnosis  of  non-calculous  cholecystitis  is  per- 
missible, the  duodenum,  stomach,  pancreas,  appendix,  and  right 
kidney  must  be  examined,  and  if  the  conjecture  is  correct,  the  gall- 
bladder will  be  found  thickened,  of  Hght  color,  with  the  lymphatic 
glands  along  the  cystic  and  common  ducts  markedly  enlarged. 
It  should  contain  tarry  bile,  and  the  mucous  membrane  should 
be  not  only  thickened,  but  covered  with  Httle  fibrinous  specks. 

For  patients  who  have  gall-stones  and  who  have  suffered  from 
attacks  of  jaundice  and  other  symptoms  of  infection  of  the  com- 
mon and  liver  ducts,  but  without  stones  in  the  ducts,  cholecystos- 
tomy is  the  operation  of  choice,  as  it  furnishes  bile  drainage. 
Cholecystectomy,  if  performed  in  this  latter  group,  should  not  be 
accomplished  by  hgating  the  cystic  duct,  as  it  may  be  important 
to  secure  bile  drainage,  and  the  duct  must  be  left  open,  or,  if 
necessary,  spHt  down  to  the  common  duct  for  this  purpose.  If 
the  cystic  duct  is  patulous,  cholecystostomy  furnishes  this  drain- 
age easily  and  safely,  and  in  case  of  future  common-duct  stone,  the 
gall-bladder  is  a  rehable  guide  to  the  common  duct  and  greatly 
faciHtates  a  secondary  procedure. 

It  should  be  borne  in  mind  that  stones  may  form  in  the  com- 
mon duct  secondary  to  an  infection  from  gall-stones  in  the  gall- 
bladder, and  especially  so  if  a  stone  has  passed  through  the  com- 
mon duct  or  has  been  removed  from  it.  It  has  been  urged  that 
the  gall-bladder  in  gall-stone  disease  is  obsolete,  and  should  be 
removed  in  every  case.  In  our  experience  there  has  been  a  slightly 
increased  hazard  and  without  compensating  increase  in  perma- 
nence of  cure  or  shortening  of  convalescence  in  the  average  case. 
We  find  indication  for  removal  of  the  gall-bladder  in  about  2  cases 
out  of  5,  but  consider  cholecystostomy  the  operation  of  choice. 


OPERATIONS    FOU    GALL-STONE    DLSEASE  435 

and  only  })crform  cholecyslectoniy  for  definite  pathologic  condi- 
tions, such  as  we  have  called  attention  to. 

The  most  common  cause  of  death  where  the  gall-bladder  alone 
was  involved  was  a  descending  infection  of  the  common  and  he- 
patic ducts.  Cholangitis  as  a  result  of  gall-stone  disease  at  once 
introduces  a  most  serious  conii)lication.  As  long  as  the  stones  are 
confined  to  the  gall-bladder  they  are,  so  to  speak,  but  a  side  issue 
to  the  possibilities  of  trouble  engendered  l)y  lodgment  in  the  deep 
ducts,  for  here  an  infection  is  lighted  up  which  may  extend  to  the 
smallest  bile-ducts,  and  over  which,  as  compared  with  gall-bladder 
disease,  we  have  but  little  control.  A  process  is  instituted  which 
may  result  in  stone  formation,  even  in  the  most  minute  bile-ducts, 
and  future  trouble  after  apparent  cure  may  be  the  result.  The 
death  of  16  patients  in  137  operations  for  gall-stones  in  the  com- 
mon-duct series  and  4  out  of  9  malignant  cases  demonstrates 
the  serious  character  of  common-duct  surgery.  Not  that  the 
operation  itself  is  particularly  difficult  or  prolonged,  but  we 
have  two  serious  elements  introduced,  namely,  jaundice  and  in- 
fection, and  the  mortality,  both  immediate  and  remote,  of  chole- 
dochotomy  depends  almost  entirely  upon  these  factors.  About 
one-third  of  all  patients  with  common-duct  stones  have  little  or  no 
jaundice  at  the  time  of  operation  and  very  little  infection.  How- 
ever, at  the  time  the  stones  pass  into  the  common  duct  the  history 
will  usually  show  that  there  had  been  both  jaundice  and  infection, 
and  during  the  acute  stage  operation  would  have  been  fraught  with 
greater  danger.  During  the  quiescent  period  operation  is  safe  in 
such  cases,  and  the  mortality,  in  our  experience,  not  more  than  2 
per  cent. 

Unfortunately,  the  majority  of  common-duct  patients  have 
either  never  had  an  intermission  or  have  passed  beyond  it,  and 
operation  is  no  longer  an  election  as  to  time,  but  a  necessity,  and, 
no  matter  how  desperate  the  condition  of  the  patient,  must  be 
done  to  save  life.  In  some  cases  the  infection  is  the  more  promi- 
nent feature,  giving  typical  ague  symptoms.  Sudden  chills,  with 
high  temperature,  followed  by  rapid  decline  and  a  little  temporary 
increase  in  jaundice,  attended  with  moderate  pain  and  often  nau- 


436  WILLIAM    J.    AXD    CHARLES    H.    MAYO 

sea,  are  pathognomonic.  In  others  there  is  Httle  infection,  but 
such  a  degree  of  bile  stasis  in  the  ducts  as  to  inA-ite  infection  after 
any  kind  of  operation.  Patients  with  extreme  jaundice  and  sub- 
cutaneous hemorrhage  will  nearly  always  bleed  to  death  from 
capillar}'  oozing.  If  purpuric  spots  exist  with  jaundice,  we  keep 
the  subjects  under  treatment  until  the  blood  will  at  least  remain 
in  the  proper  channels.  In  all  cases  of  jaundice  we  use  chlorid  of 
calcium,  following  the  ad^nce  of  Robson,  for  a  few  days  before 
operation,  but  we  are  uncertain  as  to  its  exact  value. 

Another  class  of  patients  who  have,  in  our  experience,  all  died, 
and  about  whom  we  are  not  always  able  to  foretell  the  conditions 
pre^dous  to  operation,  are  those  patients  with  obstructive  jaun- 
dice, where  no  trace  of  bile  is  to  be  found  in  the  bile-passages,  the 
common  and  hepatic  ducts  being  filled  with  clear  fluid.  The  hver 
has  been  put  out  of  action.  The  patient,  while  extremely  feeble, 
may  be  up  and  about.  The  jaundice  is  extreme,  but  is  not  neces- 
sarily accompanied  by  leaky  blood-vessels  and  subcutaneous 
hemorrhages.  We  have  had  -4  of  these  patients,  and  aU  of  them 
died  -5\-ithin  four  days.  In  two  a  little  bile  appeared  in  the  drain- 
age at  the  end  of  twenty-four  hours,  but  in  none  did  liver  action 
become  reestabhshed. 

In  a  number  of  instances  the  same  condition  was  met  with  at 
an  earlier  stage,  the  bile-ducts  being  filled  with  thick,  flocculent 
bile  of  a  dark-greenish  color,  very  much  like  that  which  occurs  in 
the  gall-bladder  during  the  acute  stage  of  cystic  duct  obstruction 
and  before  the  pigments  have  become  absorbed.  In  about  half 
of  this  group  the  liver  will  begin  to  functionate  and  the  patient 
recover.  In  reviewing  the  deaths  in  common-duct  operations, 
one  is  impressed  by  the  influence  of  jaundice,  not  only  in  ^"itiating 
the  general  health  of  the  patient,  as  shown  in  the  tendency  to 
capillar^'  bleeding,  but  even  more  important  in  the  invitation  which 
it  extends  to  infection.  Combined  jaundice  and  infection  is  the 
cause  of  most  of  the  late  deaths  from  general  debility  and  ex- 
haustion which  occur  after  a  primarily  successful  operation.  "VMiile 
we  have  had  no  cases  in  which  stones  have  reformed  in  the  gall- 
bladder after  cholecvstostomv,  we  have  had  two  cases  in  which 


OPEUATIONS    FOR    (;ALL-ST0NE    DISEASE  437 

stones  formed  in  the  coininoii  duet — after  the  removal  of  a  single 
large  stone  from  the  gall-hladder  in  one  case  and  in  the  other 
many  stones  from  both  gall-bladder  and  common-duct,  showing 
that  stone  forimilion  may  take  place  independently  of  the  gall- 
bladder, but  only  when  there  have  been  i)rimary  stones  in  this 
viscus. 

We  have  seen  a  number  of  cases  of  liver-duct  stones,  but  there 
has  always  been  a  blocking  common-duct  stone  from  the  gall- 
bladder at  the  papilla  behind  which  the  intrahepatic  calculi  had 
formed,  the  favorable  condition  of  partial  obstruction  and  mild 
infection  furnishing  the  proper  environment.  In  two  cases  we 
have  had  to  operate  a  second  time  upon  common-duct  stones  which 
had  for  their  nucleus  hepatic  duct  stones  which  had  drifted  down 
into  the  common  duct  subsequent  to  the  choledochotomy.  In 
the  1000  operations,  14.6  per  cent,  involved  the  common  duct. 


THE   DIAGNOSIS   OF   GALL-STONE   DISEASE* 

WILLIAM    J.    AND    CHARLES    H.    MAYO 


In  reviewing  the  mortality  of  1100  operations  for  gall-stone 
disease  we  have  been  impressed  with  the  very  fortunate  outcome 
of  the  operation  where  the  gall-stones  were  in  the  gall-bladder  and 
before  there  were  compHcations.  In  the  1100  cases  there  were  54 
deaths,  or  an  average  mortality  of  5  per  cent.,  counting  as  a  death 
every  operated  case  dying  in  the  hospital  without  regard  to  cause 
of  death  or  length  of  time  after  operation.  The  death-rate  in  897 
cases  where  the  disease  was  confined  to  the  gall-bladder  and  for 
benign  conditions  was  3  per  cent.  Included  in  this  group  are  acute 
and  chronic  affections,  local  peritonitis,  complicating  intestinal 
fistula,  etc.  In  456  cases  of  simple  gall-stone  disease  the  mortality 
was  less  than  one-half  of  1  per  cent,  and  compares  favorably  with 
the  interval  operation  for  appendicitis  in  individuals  of  the  same 
age  and  general  condition.  It  must  be  borne  in  mind  that  indi- 
viduals most  liable  to  this  disease  are  at  an  age  in  which  degenera- 
tions of  vital  organs  are  often  present.  The  difference  between  the 
one-half  of  1  per  cent,  mortality  in  so  large  a  group  of  cases  and  3 
per  cent,  by  adding  to  it  a  nearly  equal  number  in  which  there  were 
changes  due  to  obstruction  and  infections,  shows  the  enhanced 
danger  in  the  latter  condition.  When  we  come  to  the  group  of 
common-duct  operations,  amounting  to  14.6  per  cent,  of  the  whole 
(1  case  in  7),  we  find  a  startling  increase  in  mortality.  In  159 
operations  for  common-duct  stones  the  mortality  was  10  per  cent., 
however,  only  6^  per  cent,  within  three  weeks,  3}^  per  cent,  later 
from  anemia  and  general  debility,  etc.  Still  more  impressive  is  the 
fact  that  43  cases,  or  4  per  cent.,  had  developed  malignant  diseases, 

*  Reprinted  from  the  "Clinical  Review,"  May,  1905. 
438 


THE    DIAGNOSIS   OF   GALL-STONE    DISEASE  439 

and  the  operative  mortality  was  "21  per  cent.  In  practically  all 
these  cancers  gall-stone  irritation  could  he  shown  to  he  the  cause 
of  the  malignancy.  This  brings  up  the  vital  questions:  Is  it  right 
and  just  that  so  large  a  percentage  of  patients  should  be  subjected 
to  the  dangers  consequent  upon  delayed  operation,  to  say  nothing 
of  the  prolonged  suffering  and  invalidism  entailed?  Can  the  diag- 
nosis be  made  while  the  conditions  are  favorable,  the  mortality 
so  low  as  to  be  largely  accidental,  and  the  cure  almost  certain? 

We  have  no  hesitation  in  saying  that,  as  a  rule,  the  diagnosis 
can  be  made  while  the  conditions  are  favorable.  There  are,  of 
course,  some  exceptional  cases  which  cannot  be  correctly  diag- 
nosticated, but  the  percentage  of  complications  can  be  reduced  to  a 
minimum.  Even  a  superficial  inquiry  into  the  histories  of  the 
common-duct  series  will  at  once  demonstrate  the  fact  that  in  the 
vast  majority  the  diagnosis  could  have  been  arrived  at  in  the  early 
stages  and  a  safe  operation  performed. 

During  the  initial  period  of  any  special  field  of  surgery  the 
differentiation  of  the  surgical  from  the  medical  cases  is  uncertain, 
difficult,  and  often  impossible.  Perhaps  the  greatest  obstacle 
to  be  overcome  is  the  pseudo-knowledge  and  prejudice  handed  down 
to  us  by  a  literature  founded  upon  conjecture  and  misconception. 
Once  clear  of  the  atmosphere  of  this  fog,  the  diagnosis  begins  to  be 
easy,  and  is  capable  of  intelligent  solution.  The  reasons  for  the 
symptoms  become  clear,  and,  like  every  truth  in  nature,  is  so  simple 
that  the  wonder  of  it  is  that  it  was  not  explained  before.  One  can 
almost  mourn  for  our  old  favorites,  "bilious"  and  "hepatic"  fever, 
"gastralgia,"  "stomach  cramps,"  and  a  host  of  similar  delusions 
based  upon  the  "feehngs"  of  the  patient,  while  the  true  secret  lay 
buried  under  the  term  gall-stones,  an  "innocent"  postmortem 
finding  until  resurrected  by  the  surgeon. 

There  are  a  few  anatomic  facts  which  will  explain  most  of  the 
symptomatology  of  gall-stone  disease.  The  gall-bladder  is  an 
offshoot  of  the  biliary  apparatus,  and  seems  not  at  all  essential  for 
health  or  comfort.  It  is  about  three  inches  in  length,  and  holds 
1}/^  ounces  of  bile.  The  base  of  the  gall-bladder  is  slightly  dilated, 
and  forms  a  little  pouch  by  the  reduplication  of  the  mucous  mem- 


440  WILLIAM   J.    AND    CHARLES   H.    MAYO 

brane  (the  pelvis) .  The  cystic  duct  does  not  leave  from  the  lowest 
part,  but  at  a  point  on  the  inner  wall  slightly  elevated  above  the 
neck,  and  is  about  1  inch  in  length.  The  common  duct  is  slightly 
over  3  inches  long,  of  which  somewhat  over  1  inch  lies  exposed  in 
the  right  margin  of  the  gastrohepatic  ligament,  the  remainder 
lying  behind  the  second  portion  of  the  duodenum  and  between  it 
and  the  pancreas.  It  is  the  latter  portion  which  is  so  intimately 
associated  with  the  etiology  of  the  pancreatitis  from  cholangitic 
affections  which  extend  from  the  hepatic  to  the  pancreatic  ducts. 

The  blood-supply  of  the  gall-bladder  is  through  the  cystic  artery, 
usually  from  the  hepatic,  but  sometimes  from  the  superior  pan- 
creaticoduodenal artery,  which  makes  it  liable  to  accidental  trau- 
matism during  common  duct  operations,  and  leads  to  the  belief  that 
the  injury  is  to  the  hepatic  artery.  In  a  like  manner  a  large  vein 
occasionally  crosses  the  common-duct,  and  when  injured,  is  often 
supposed  to  be  the  portal  vein.  The  gall-bladder  has  no  lymphatic 
glands  and  but  few  lymph-channels.  There  is  one  gland  at  the 
juncture  of  the  gall-bladder  and  cystic  duct,  another  at  the  cystic 
duct  into  the  common  duct,  and  a  small  number  closely  associated 
with  the  common  duct.  Murphy  has  especially  called  attention 
to  the  influence  of  this  peculiar  lymphatic  drainage  on  the  systemic 
effects  of  biliary  infections.  The  nerve-supply  is  most  interesting. 
Lennander  showed  that  the  abdominal  viscera  had  no  sensation, 
but  that  the  parietal  peritoneum  was  exquisitely  sensitive.  There 
is  one  exception  to  this  rule:  Jonas  has  pointed  out  the  branches 
which  pass  from  the  four  lower  dorsal  and  two  upper  lumbar  nerves 
along  the  diaphragm.  The  terminal  filaments  pass  to  the  common 
and  cystic  ducts  and  neck  of  the  gall-bladder,  accounting  for  the 
deep  median  line  pain  of  the  colic  and  the  attendant  spasm  of  the 
diaphragm. 

Gall-stones  are  the  result  of  cholecystitis.  The  bacteria  prob- 
ably reach  the  gall-bladder  through  the  bile-current  (Lartigau), 
rather  than  by  an  ascending  infection  from  the  duodenum  by  way 
of  the  common  duct.  The  portal  radicals  constantly  carry  organ- 
isms to  the  hver,  and  those  not  directly  destroyed  are  excreted  with 
the  bile.     The  majority  of  people  subject  to  gall-stones  have  had 


THE    DIAGNOSIS   OF   GALL-STOXK    DISEASE  441 

mild  attacks  of  cholecystitis  at  various  times  before  the  formation 
of  stones,  as  observed  by  Musser.  We  have  been  able  to  r-orifirm 
this  observation  in  a  lar|i;e  series  of  cases. 

First  Stage. — The  diagnosis  of  gall-stone  disease  is  based  on  tlie 
colic.  The  j)atient  is  seized  with  a  severe  crami)ing  pain  in  the 
midline,  just  beneath  the  ensiform  cartilage;  the  pain  radiates 
usually  to  the  right,  but  occasionally  to  the  left.  It  may  pass 
through  to  the  back  or  up  through  the  sternum.  The  typical  colic 
lasts  from  a  few  minutes  to  several  hours,  and  is  relieved  suddenly 
by  nausea  and  vomiting  or  a  feeling  of  movement  of  gas  in  the 
bowels,  unless  cut  short  by  anodynes.  There  is  no  quickening  of 
the  pulse  nor  elevation  of  the  temperature.  Why?  Because  the 
bladder  has  few  lymphatic  channels  and  no  glands.  The  distensi- 
bility  of  the  gall-bladder  relieves  tension,  so  that  the  attack  is  over 
before  absorption  can  take  place.  The  patient,  once  relieved,  feels 
quite  well,  eats  and  digests,  and  beyond  a  little  rigidity  of  the  right 
upper  rectus  muscle,  has  no  physical  evidence  of  disease.  We  may 
differentiate  it  from  appendiceal  colic  by  the  fact  that  the  pain  is 
above  the  umbilicus  and  radiates  upward.  Appendicular  colic 
may  cause  nausea  and  the  pain  may  center  at  the  umbilicus,  on 
account  of  its  nerve-supply  being  the  same  as  the  mesentery  of  the 
small  intestine.  Ordinarily,  in  the  latter  instance,  there  will  be 
an  early  history  of  appendicitis,  in  which  the  patient  is  confined  to 
bed  for  several  days.  Some  rigidity  of  the  right  lower  rectus  will 
usually  be  found.  The  most  confusing  cases  are  those  in  which 
the  appendix  lies  in  the  pelvis,  but  the  pain  radiates  downward  and 
often  to  the  left  or  all  over  the  lower  abdomen. 

Right  renal  colic  can  be  differentiated  by  the  pain  passing 
through  the  loin,  being  most  intense  behind  and  radiating  down- 
ward to  the  penis,  testicle,  or  ovarian  region,  with  a  history  of  some 
urinary  disturbance.  The  tenderness  to  pressure  is  greatest  just 
below  the  twelfth  rib  behind. 

The  second  stage  of  gall-stone  disease  means  an  obstruction  at 
the  pelvis  of  the  gall-bladder.  The  attack  may  begin  as  a  typical 
colic,  but  instead  of  passing  off  quickly,  it  is  replaced  by  a  tender- 
ness in  this  region,  and  a  more  or  less  definite  tumor  of  the  gall- 


442  WILLIAM   J.    AND    CHARLES    H.    MAYO 

bladder  can  often  be  felt.  The  pulse  may  quicken  a  few  beats  and 
the  temperature  rise  to  101.5°  F.,  seldom  more  and  usually  less, 
even  with  pus  present,  and  why.'*  Because  of  the  lack  of  lymphatic 
supply.  The  only  gland  available  lies  beyond  the  stone.  This 
group  must  be  differentiated  from  the  ulcer  of  the  duodenum  with 
chronic  protected  perforation  by  the  history  of  gastric  disturbance 
and  of  dieting  to  reheve  the  distress,  which  so  often  attends  upon 
ulcer.  With  cystic  impaction  the  appetite  remains  good.  The 
former  disease  is  more  frequent  in  males,  the  latter,  more  frequent 
in  females. 

The  third  stage  comes  from  the  contraction  of  the  distended  gall- 
bladder with  slow  absorption  of  the  fluids.  This  is  often  attended 
with  peritonitis,  and  we  may  have  a  slight,  quickly  receding  jaun- 
dice, due  to  interference  with  common-duct  drainage  from  the 
plastic  peritoneal  deposits.  The  case  is  now  typically  one  of 
chronic  stomach  trouble,  dyspepsia,  etc.  There  may  be  recurring 
attacks  of  regional  peritonitis,  but  no  more  distinct  coHcs.  Ad- 
hesions to  the  pylorus  may  interfere  \sdth  gastric  motihty,  resulting 
in  dilatation  of  the  stomach,  etc.  This  phase  of  the  disease  may 
be  differentiated  from  gastric  ulcer  by  the  early  history  of  colic  and 
by  the  lack  of  direct  connection  between  food  and  distress,  etc. 
Occasionally  we  may  have  an  acute  perforation  of  the  gall-bladder 
into  the  free  peritoneal  cavity.  More  often  a  slow  process  of  ulcer- 
ation into  the  colon  occurs,  and  temporarily  occasions  a  mucous 
colitis,  or  into  the  duodenum  or  stomach,  causing,  perhaps,  acute 
but  temporary  pyloric  obstruction. 

Fourth  Stage. — The  stone  may  pass  into  the  cystic  duct  and  give 
rise  to  sudden  attacks  of  fever  (temperature,  103°  or  104°  F.,  ^dth 
chills  and  quick  pulse),  lasting  a  few  hours  and  recurring  at  ir- 
regular intervals  of  hours  or  days.  This  is  because  the  duct  is  not 
easily  dilated;  tension  is,  therefore,  high,  and  a  plentiful  supply  of 
lymphatics  permits  rapid  absorption.  The  pain  is  boring  and  deep 
seated,  and  may  last  for  a  number  of  hours  or  several  days  con- 
tinuously as  the  stone  advances.  There  is  often  temporary 
jaundice.  The  acuteness  of  the  symptoms  varies  greatly,  depend- 
ing on  the  distensibility  of  the  gall-bladder,  on  its  ability  to  relieve 


THE    DIAGNOSIS   OF   GALL-STONE    DISEASE  448 

back  pressure,  and  on  the  dilatability  of  the  duct.  This  stage  is 
the  least  characteristic  of  any. 

Fifth  Stage. — The  stone  passes  into  the  common  duct.  The 
symptoms  of  stone  in  the  common  duct  depend  upon  two  factors, 
infection  and  jaundice.  In  the  acute  stage  both  are  present  in  a 
varying  degree.  As  a  rule,  the  temperature  assumes  a  charac- 
teristic malarial  curve,  i.e.,  chilly  sensations  and  rigors,  with  sudden 
sharp  rise  in  temperature,  lasting  a  few  hours,  perhaps  as  high  as 
107°,  usually  103°  to  105°  F.,  showing  the  influence  of  free  lym- 
phatic absorption.  Jaundice  during  the  acute  stage  is  present  in  a 
varying  degree,  and  with  each  exacerbation  of  infection  there  is  a 
slight  increase  in  the  icterus,  followed  by  diminution,  changing 
perhaps  once  or  more  in  twenty-four  hours.  It  does  not  follow 
that  subsidence  of  reaction  or  clearing  up  of  jaundice  means  that 
the  stone  has  passed  into  the  duodenum.  In  about  one-fourth  of 
the  cases  there  is  a  period  of  quiescence  which  may  last  weeks  or 
months,  the  only  symptoms  complained  of  being  gastric  disturb- 
ance. There  is  also  some  loss  of  w^eight.  The  interval  is  the  safe 
time  to  operate,  and  the  death-rate  at  this  period  is  probably  not 
above  2  per  cent. 

Sooner  or  later  changes  develop  in  the  walls  of  the  common  and 
hepatic  ducts,  and  not  infrequently  in  the  pancreas.  The  infection 
becomes  more  active,  the  jaundice  increases,  and  there  is  a  more 
rapid  loss  of  flesh  and  a  progressive  anemia.  The  safe  time  has 
passed,  and  the  mortality  is  from  10  to  30  per  cent,  in  the  last 
resort  operation. 

In  cases  of  common-duct  stone  a  tumor  seldom  occurs,  as 
pointed  out  by  Courvoisier,  although  we  have  seen  a  palpable  gall- 
bladder due  to  a  secondary  stone  lodged  in  the  cystic  duct,  causing 
a  tumor  of  the  gall-bladder  by  preventing  the  escape  of  the  secre- 
tions. As  a  rule,  in  all  duct  cases,  both  cystic  and  common,  there 
is  an  unconscious  resistance  to  deep  pressure  over  the  upper  right 
rectus  muscle  during  inspiration. 

Dividing  the  pathologic  condition  into  stages  is  merely  for  the 
purpose  of  calling  attention  to  the  most  common  symptoms  and 
the  reasons  therefor. 


444  WILLIAM   J.    AND    CHARLES   H.    MAYO 

This  brings  us  to  a  consideration  of  jaundice.  If  it  can  be  said 
that  gall-stones  have  a  normal  habitat,  it  is  in  the  gall-bladder,  and 
they  are,  therefore,  entirely  apart  from  the  bile-current.  Jaundice 
has  no  part  in  the  diagnosis  of  gall-bladder  stone,  and  when  present, 
means  a  complication  arising  in  one  of  several  different  ways : 

First,  stones  in  the  gall-bladder  may  give  rise  to  cholecystitis ; 
the  infection  travels  to  the  common  duct  and  produces  a  cholangitis 
with  jaundice. 

Second,  a  local  peritonitis  is  established,  and  the  plastic  deposit 
in  the  fissure  of  the  liver  compresses  the  common  duct  and  causes 
jaundice. 

Third,  a  stone  impacted  in  the  cystic  duct  may  compress  the 
common  duct. 

Fourth,  the  cholangitic  infection  may  extend  into  the  pan- 
creatic ducts,  causing  chronic  pancreatitis  and  jaundice. 

Jaundice  from  malignant  disease  has  usually  the  early  history 
of  gall-stones,  and  there  is  apt  to  be  a  prolonged  period  of  quiescence. 
The  icterus  is  noticed  accidentally,  as  while  shaving,  is  not  ac- 
companied by  pain,  steadily  increases,  and  does  not  vary  day  by 
day  in  the  manner  so  characteristic  of  common-duct  stones.  A 
nodular  tumor  can  usually  be  felt  in  malignant  disease.  Jaundice 
from  hypertrophic  cirrhosis  of  the  fiver  is  accompanied  by  painful 
attacks,  and  the  great  size  of  the  fiver  is  easily  demonstrated. 
Cirrhosis  of  the  liver  may  produce  jaundice,  but  the  alcoholic 
history  and  enlarged  spleen  and  ascites  so  often  present  permit 
differentiation.     . 

Catarrhal  jaundice,  so  common  in  young  people,  has  nothing 
in  the  examination  or  history  to  suggest  biliary  calculus. 

The  urine  should  be  carefully  examined,  although  there  is 
nothing  characteristic  about  it  beyond  the  possibility  of  the  pres- 
ence of  bile.  Immediately  following  the  attack,  examination  of 
the  feces  may  disclose  calculi,  but  this  does  not  often  happen.  In 
our  experience  it  is  nearly  as  common  for  stones  (especially  large 
ones)  to  ulcerate  into  the  duodenum,  stomach,  or  colon,  as  to  pass 
through  the  common  duct,  and  in  either  case  there  are  probably 
others  which  remain. 


THE    DIAGNOSIS    OF    GALL-STONK    UISEASK  44.3 

Finally,  tluTc  are  a  few  i)atient.s  who  come  to  us  with  severe 
syiiiptoiiis  in  tlie  ujjper  abdomen — so  serious  that  if  they  had  been 
located  in  the  pelvis  or  appendiceal  region,  operative  interference 
wouM  liave  licen  instituted  at  a  much  earh'er  period.  We  may  not 
be  able  to  make  a  pathologic  diagnosis,  but  we  can  make  a  surgical 
diagnosis — that  is,  we  can  demonstrate  beyond  question  that  the 
cause  of  the  symptoms  is  one  of  several  conditions,  all  of  which  are 
surgical,  and,  such  being  the  case,  o|)eration  should  be  instituted 
before  gross  pathologic  changes  nuike  the  difl'erential  diagnosis  more 
certain,  but,  unfortunately,  the  prognosis  less  favorable.  It  is  a 
question  to  be  decided  on  its  merits,  and  the  patient  should  be 
allowed  the  choice  in  doubtful  cases.  We  would  not,  however,  ad- 
vise a  reckless  resort  to  the  knife  for  exploratory  purposes.  We 
should  avail  ourselves  of  all  the  diagnostic  measures  to  be  obtained 
from  the  laboratory,  from  the  physical  examination,  and,  beyond 
all,  from  the  history  of  the  patient;  but  it  is  a  false  conservatism 
which  stands  in  the  way  of  early  operative  interference  in  gall- 
stone disease. 


SOME  OBSERVATIONS  ON  CASES  INVOLVING 
OPERATIVE  LOSS  OF  CONTINUITY  OF  THE 
COMMON  BILE-DUCT,  WITH  THE  REPORT 
OF  A  CASE  OF  ANASTOMOSIS  BETWEEN 
THE  HEPATIC  DUCT  AND  THE  DUO- 
DENUM* 

WILLIAM    J.    MAYO 


In  1100  operations  upon  the  gall-bladder  and  bile-passages 
(C.  H.  and  W.  J.  Mayo)  up  to  March  27,  1905,  159  were 
upon  the  common  duct  of  the  liver.  Of  this  number,  7  had  com- 
plete loss  of  the  continuity  of  the  common  bile-duct  as  a  direct 
result  of  the  operation;  5  were  intentionally  produced  in  the  at- 
tempt to  remove  a  malignant  neoplasm ;  1  was  caused  accidentally, 
and  1  followed  an  extensive  operation  for  gall-stone  disease.  This 
case  is  reported  in  detail  herewith. 

The  possibility  of  union  between  the  divided  ends  of  the  com- 
mon duct  was  first  brought  to  our  attention  in  an  unfortunate 
manner.  During  the  removal  of  a  deeply  situated  and  densely 
adherent  gall-bladder  the  common  duct  was  accidentally  divided. 
The  ends  were  widely  separated  before  the  accident  was  dis- 
covered, rendering  detection  of  the  distal  end  a  matter  of  some 
difficulty.  The  proximal  fragment  was  easily  identified  by  the 
escape  of  bile.  The  common  duct  was  of  normal  size,  which  ren- 
dered suturing  difficult  and  uncertain,  but  it  was  accomplished  in 
the  following  manner:  three  catgut  sutures  were  placed  in  the 
remnants  of  peritoneum,  adhesions,  and  right  margin  of  the  gastro- 
hepatic  ligament,  drawing  the  duct  ends  into  apposition;  5  fine 
catgut  sutures  were  then  introduced  through  all  the  coats  of  the 

*  Reprinted  from  "Annals  of  Surgery,"  July,  1905. 
446 


OPERATIVE  LOSS  OF  CONTINUITY  OF  COMMON    HIIJO-Dl  CT       447 

coinnioii  duct  Ihroufiliout  tlircc-fourllis  of  its  circiiiiifcroncc,  leav- 
ing a  ga{)  anteriorly  for  drainage.  We  siniidy  rei)roduced  as 
nearly  as  we  could  the  condition  which  exists  after  choledochotomy 
for  stone.  The  external  hile  discharge  ceased  in  sixteen  days; 
the  patient  was  discharged  on  the  twenty-second  day,  and  has  had 
no  further  trouble — now  nearly  two  years. 

This  accident  taught  us  that  fine  catgut  would  hold  a  sufficient 
length  of  time  for  union  to  take  place,  and  that  it  is  not  open  to  the 
objection  silk  would  have  because  of  the  liability  to  induce  secondary 
stone  formation,  such  as  occurred  in  the  reported  case  of  Homans. 
It  also  demonstrated  that  no  harm  followed  taking  all  the  duct 
coats  firmly  in  a  single  suture. 

Within  a  year  we  had  an  opportunity  to  apply  the  same  technic 
to  a  case  of  carcinoma  of  the  gall-bladder  which  extended  down  the 
cystic  duct  to  the  common  duct,  and  in  which  the  gall-bladder, 
cystic  duct,  and  three-fourth  inch  of  the  common  duct  were  excised. 
In  this  case  the  second  portion  of  the  duodenum  was  loosened  from 
its  bed,  after  the  manner  of  Kocher  in  his  gastroduodenostomy; 
the  intestine  was  drawn  to  the  right  and  held  by  catgut  sutures  to 
the  neighboring  tissues.  The  patient  made  a  good  recovery  and 
remained  well  until  a  return  of  the  growth  thirteen  months  later 
("Medical  Record,"  April  30,  1904). 

The  condition  of  the  third  case  was  due  to  a  small,  very  hard, 
malignant  growth  in  the  common  duct  causing  obstructive  jaundice. 
The  tumor  and  nearly  an  inch  of  the  common  duct  were  excised, 
and  the  ends  sutured  as  in  Cases  I  and  II.  The  patient,  however, 
died  from  capillary  hemorrhage  on  the  third  day,  without  fully 
recovering  from  the  initial  shock. 

Our  first  attempt  at  direct  union  of  the  common  bile-duct  to 
the  duodenum  came  about  through  an  effort  to  remove,  what  we 
supposed  at  the  time  to  be,  a  stone  impacted  in  the  common  duct, 
just  in  the  margin  of  the  pancreas,  and  underneath  the  edge  of  the 
duodenum.  The  duodenum  was  loosened  on  its  right  side,  turned 
upward  and  to  the  left.  The  duct  was  incised  and  the  supposed 
stone  found  to  be  a  typical  duct  carcinoma,  hard,  grayish  white, 
and  well  defined.     It  was  excised,  and  the  space  closed  by  catgut 


448  WILLIAM  J.  :mayo 

sutures.  The  common  duct  was  reinserted  at  a  new  location  in  the 
duodenum,  at  a  point  where  it  was  covered  by  peritoneum,  after 
the  plan  so  successfully  used  by  Halsted;  catgut  was  again  used  as 
a  suture  material.  A  wick  drain  was  inserted  down  to  the  suture 
line.  This  was  a  mistake.  There  was  no  leakage  until  the  drain 
was  removed  at  the  end  of  a  week.  The  plastic  lymph,  which 
should  have  protected  the  suture  line,  became  entangled  in  the 
meshes  of  the  gauze,  causing  difficulty  and  delay  in  removal,  and 
so  disturbed  the  union  as  to  allow  a  minute  fistula  to  form.  This 
gradually  increased  in  size  from  the  biliary  and  duodenal  dis- 
charge until  the  patient  was  exhausted  and  died  at  the  end  of  the 
eighth  week.  The  lesson  taught  was  that  a  gauze  drain  should 
never  be  placed  directly  against  an  anastomotic  suture  line.  The 
feasibihty  of  union  between  the  duct  and  the  duodenum  at  a  peri- 
toneal covered  situation  was  manifest  by  the  temporary  recovery 
of  the  patient. 

The  fifth  case  was  reported  in  conjunction  "v^ith  a  paper  on 
cholecystectomy  at  the  meeting  of  the  American  Medical  Associa- 
tion, Surgical  Section,  1900  ("The  Journal,"  December,  1900). 
In  this  case  we  excised  the  cancerous  gall-bladder  with  a  tongue- 
like overlying  portion  of  the  Hver,  together  with  the  whole  of  the 
cystic  duct  and  part  of  the  common  and  hepatic  ducts.  An  un- 
successful effort  at  union  of  the  deep  duct  was  made.  The  opera- 
tion was  easy  o^-ing  to  the  fact  that  the  Hver  was  exceedingly 
movable  and  the  ducts  elongated.  All  the  bile  escaped  from  the 
external  wound,  to  the  great  distress  of  the  patient,  until  death 
occurred  nine  weeks  later. 

The  sixth  case,  which  concerned  the  successful  removal  of  a 
carcinoma  of  the  papilla  and  diverticulum  of  Vater,  was  reported 
in  the  "St.  Paul  Medical  Journal,"  June,  1901,  but  has  no  bearing 
on  the  subject  under  discussion. 

The  writer  has  briefly  reviewed  some  features  of  these  cases  in 
order  to  illustrate  a  few  facts  which  experience  teaches,  and  which 
may  be  summarized  as  follows:  First,  the  common  duct  may  be 
united  end  to  end,  by  through-and-through  catgut  sutm-es.  It  is 
essential  that  a  few  supporting  sutures  should  be  placed  in  the 


Fig.  44. — Liver  raised  upward.     End  of  h?patic  duct  freed  and  sutures  placed  ready  to  draw  duodenum 
into  position.     Note  that  gall-bladder  was  removed  at  previous  operation. 


Fig.  43. — Fixation  sutures  tied,  duodenum  incised,  and  posterior  row  of  through-and-through  sutures 

in  place. 


I 


()l'l';i{,\  TIN  !•;    LOSS  OK  CON'I'IMI'I'V  OF  CO.M.MCJN    lU  I.K-I)l  CT       449 

siiiToiUKliiif,'  tissues,  .•iiid  lliiil  a  portion  of  I  lie  circiiinrcn'ticc  of  tlie 
line  of  iiiiiou  should  Ix"  icfl  o|)cu  for  relief  of  tension  and  draiuiige. 
Second,  Liie  eoninion,  and  in  eerfiiiii  cases  tlie  liepalic,  duel  may  he 
iniplanled  into  tlie  duodenum,  jn-ovided  a  portion  of  the  intestine 
cov^ered  with  peritoneum  be  chosen  for  the  purpose.  Third,  to 
facilitate  these  operations,  the  second  portion  of  the  duodenum 
should  be  loosened  and  drawn  to  the  ri^ht  and  held  by  fixation 
sutures,  preventin<:f  tension  on  the  duct  suture  line.  ]"\Mirtli, 
drainage,  if  necessary,  shoidd  be  pliable,  covered  with  rubber 
tissue,  and  placed  as  distant  to  the  suture  line  as  will  ser\-e  the 
purpose  of  protection  against  leakage. 

In  the  following  case  the  successful  outcome  was  due  to  the 
care  with  which  we  w^ere  able  to  carry  out  these  details. 

Case  VII. — C'holecystectomi/  and  Choledochotomy,  Followed  by 
Extcnsire  Stricture  of  Common  Duct,  u'JiicIi  vas  Relieved  by  Secondary 
Anafftomonis  between  the  Hepatic  Duct  and  Duodenum. — Mrs.  L.  I., 
aged  twenty-two  years,  mother  of  two  children;  admitted  to  St. 
Mary's  Hospital  June  30,  1903,  with  the  following  history:  For 
four  years  has  suffered  with  "stomach  cramps"  and  pain  in  right 
hypochondrium,  which  passed  through  to  the  right  shoulder.  In 
one  of  these  attacks  she  had  been  slightly  jaundiced.  Ten  days 
ago  an  attack  similar  to  the  previous  ones  came  on,  but  did  not 
stop  as  before.  The  intense  pain  subsided,  but  was  replaced  by 
frequent  colicky  pains,  nausea,  chills,  and  fever.  Stools  were  clay 
colored.  Family  and  personal  history  other  than  above,  negative. 
Examination,  a  slightly  built  woman,  5  feet  2  inches  in  height; 
weight,  08  pounds;  heart  and  lungs,  normal;  urine  contained  bile, 
a  trace  of  albumin,  and  a  few  hyaline  casts.  A  moderate  leukocy- 
tosis was  present;  temperature,  101°  F. ;  pulse,  110;  icterus  fairly 
well  marked;  deep  pressure  over  gall-bladder  region  during  in- 
spiration developed  resistance  and  an  indefinite  sense  of  tumefac- 
tion.    No  other  relevant  physical  findings. 

Diagnosis. — Gall-stones  in  gall-bladder  and  common  duct. 

Operation  July  1,  1903.  Through  a  4-inch  straight  incision  in 
upper  right  rectus  muscle  a  contracted,  thick-walled  gall-bladder 
filled  with  stones  was  exposed.  The  superior  angle  of  the  incision 
was  carried  upward  and  inward  along  the  costal  margin,  after  the 
method  of  Bevan,  and  the  common  duct  palpated  and  inspected. 
It  was  full  of  stones  and  debris  and  closely  adherent  to  the  duo- 
voL.  1—29 


450  WILLIAM   J.    MAYO 

denum  and  surrounding  structures.  The  gall-bladder  was  removed 
from  below  upward  without  opening  its  cavity,  and  the  cystic  duct 
was  slit  downward  into  the  common  duct,  which  was  freely  opened. 
The  common  duct  was  dilated  to  the  size  of  a  lead-pencil,  and  filled 
with  putty -like  material  and  stones,  all  of  which  was  removed  with 
a  scoop.  During  the  process,  dark,  flocculent  bile  appeared.  The 
cleaning  process  was  difficult,  and  when  completed,  the  duct  was 
seen  to  be  greatly  thickened  and  the  mucous  membrane  eroded. 
A  few  interrupted  catgut  sutures  were  introduced  in  the  incised 
duct  up  to  the  entrance  of  the  cystic  duct.  At  this  point  an  open- 
ing was  left  into  which  a  fish-tailed  rubber  tube,  one-quarter  inch 
in  diameter,  was  introduced  and  held  by  two  fine  catgut  sutures. 
Around  this  a  moderate  amount  of  gauze  was  placed  and  protected 
by  gutta-percha  tissue,  the  whole  being  allowed  to  protrude  from 
the  upper  angle  of  the  abdominal  incision.  The  operation  lasted 
three-quarters  of  an  hour.  Patient  reacted  well,  but  was  in  rather 
a  critical  condition  for  several  days,  until  normal  bile  in  quantity 
made  its  appearance.  Drains  all  out  on  the  eleventh  day;  patient 
discharged  on  the  twentieth  day  with  a  healed  wound,  bile  freely 
present  in  the  stool. 

Readmitted  to  hospital  May  25,  1904.  Patient  stated  that  for 
about  five  months  she  had  been  quite  well,  doing  her  housework, 
and  had  gained  10  pounds  in  weight.  About  this  time  she  noticed 
some  general  skin  pruritus,  slight  jaundice,  and  an  unpleasant  sensa- 
tion in  the  stomach.  This  rapidly  increased,  and  was  followed  by 
chills  and  fever,  clay-colored  stools,  and  severe  illness.  She  was  in 
bed  for  five  weeks ;  eventually,  the  old  drainage  tract  in  the  former 
incision  opened  up  and  discharged  bile  freely,  with  marked  im- 
provement. From  that  time  until  admission  the  fistula  discharged 
at  intervals  with  temporary  betterment.  The  periods  during 
which  the  fistula  remained  closed  were  marked  by  severe  symptoms, 
jaundice,  nausea,  chills,  and  fever.  At  the  time  of  readmission 
fistula  was  not  open.  Patient  emaciated,  weight  81  pounds, 
jaundice  extreme,  chills,  fever,  and  sweating,  with  colicky  pains 
of  daily  occurrence.  Pulse-rate,  120;  temperature  variable  from 
subnormal  to  103°  F. ;  general  debility  marked. 

May  26,  1904,  under  ether  anesthesia,  and  with  the  patient 
in  Robson  position,  a  5-inch  incision  was  made  just  internal  to 
and  parallel  with  the  cicatrix  of  the  former  wound,  i^  dense 
tangle  of  adhesions  was  encountered,  involving  transverse  colon, 
duodenum,  and  stomach,  on  the  one  side,  and  the  liver  and  ducts, 
on  the  other.  By  following  the  remains  of  the  fistulous  tract 
carefully  and  keeping   close  to   the  liver  the   original   drainage 


Fig.  46. — All  posterior  sutures  in  place  and  tied,  ready  for  lateral  and  anterior  sutures. 


OPERATIVE  UJSS  OF  CONTIXUITY  OF  COMMON  BILF-DUCT         4.j1 

openinfjat  thcsitcof  the  cystic  diict  was  discoxxTcd.  The  hcj)atic 
(hicL  was  dilated  and  easily  admitted  the  tip  of  the  index-linger 
to  the  primary  division.  'I'lie  common  <hict  was  rethiced  fjy  cica- 
tricial contraction  to  a  fibrous  cord,  alon^  which  could  be  traced 
a  little  stain  of  bile.  During  the  separation  of  adhesions  it  was 
noted  that  the  duodenum  overlapped  the  remains  of  the  common 
duct  antl  formed  one  wall  of  the  fistulous  tract  in  its  deeper  por- 
tion. The  external  incision  was  continued  to  the  sternal  notch 
and  the  overlying'  liver  held  upward.  The  duodenum  was  still 
further  mobilized.  The  hepatic  duct  was  freed  from  its  attach- 
ment to  the  fistulous  tract  and  from  the  remains  of  tlie  common 
duct;  the  adhesions  posteriorly  were  not  otherwise  disturbed,  and 
served  a  very  useful  purpose.  About  3  inches  from  the  pj'lorus 
the  duodenum  was  caught  with  3  catgut  sutures  and  fastened 
firmly  to  the  adhesions  and  scar  tissue  about  the  hepatic  duct, 
so  that  it  was  brought  into  contact  with  the  end  of  the  hepatic  duct 
(Fig.  4-4).  At  the  point  of  easy  contact  an  elliptic  piece  of  all  the 
coats  of  the  duodenum  was  excised,  of  about  the  same  diameter  as 
the  open  end  of  the  hepatic  duct  (Fig.  45),  and  4  or  5  catgut  sutures 
were  introduced  from  the  nuicous  side  through  all  the  coats  of  both 
duet  and  intestinal  wall.  In  this  way  the  posterior  line  of  the 
anastomosis  was  completed.  By  alternately  placing  a  suture  ex- 
ternally and  internally  the  sides  were  built  up  in  a  similar  manner 
to  a  two-row  intestinal  anastomosis,  except  that  only  the  inner 
row"  penetrated  the  duct-wall.  At  the  upper  part  the  few  remain- 
ing sutures  were  all  placed  before  they  were  tied  (Fig.  46).  The 
duodenum  was  still  further  attached  laterally  and  anteriorly  to  the 
scar  tissue,  covering  the  liver  and  ducts  by  catgut  sutures,  making 
a  broad  area  of  attachment.  A  drain  of  rolled  gutta-percha  tissue 
was  i)laced  at  the  upper  angle  of  the  abdominal  incision,  and 
another  at  the  lower,  but  each  at  a  considerable  distance  from  the 
anastomotic  suture  line.  The  abdominal  incision  was  then  closed. 
Time  of  operation,  fifty  minutes.  Patient  made  an  uninterrupted 
recovery.  There  was  no  leakage  of  anj^  kind;  drains  were  re- 
moved on  the  sixth  day;  patient  discharged  on  the  sLxteenth  day. 
Patient  reexamined  ten  months  after  the  operation  (March  i'i, 
1905),  had  gained  31  pounds  in  weight,  and  was  in  excellent  health. 
The  original  renioval  of  the  gall-bladder  was  unfortunate,  as  a 
cholecystenterostomy  would  have  been  far  easier  as  a  second  opera- 
tion, i)rovided,  of  course,  that  drainage  would  have  restored  the 
function  to  a  sufficient  extent.  Since  that  time  we  have  been  more 
conservative  about  the  removal  of  the  gall-bladder  in  connection 
with  common-duct  surgery. 


\  REVIEW  OF  1500  OPERATIONS  UPON  THE 
GALL-BLADDER  AND  BILE-PASSAGES, 
WITH  ESPECIAL  REFERENCE  TO  THE 
MORTALITY* 

WILLIAM    J.    MAYO 


The  three  most  important  considerations  in  the  surgical  treat- 
ment of  any  disease  are,  first,  the  mortality;  second,  the  perma- 
nence of  cure;  third,  the  disability  arising  from  the  operation  itself. 
The  following  investigation  has  been  conducted  with  a  view  to 
elucidating  the  truth  in  regard  to  these  essentials. 

Mortality. — The  first  question  to  be  considered  concerns  the 
operative  mortahty.  In  the  1500  operations  performed  on  the  gall- 
bladder and  bile-passages  between  June  24, 1891,  and  May  1, 1906 
(C.  H.  and  W.  J.  Mayo),  there  were  66  deaths — 4.43  per  cent.  In 
the  first  1000  cases  the  death-rate  was  5  per  cent.;  in  the  last  500, 
3.2  per  cent.  This  includes  acute  perforations  T\ith  septic  periton- 
itis and  mahgnant  disease.  These  statistics  give,  as  an  operative 
death,  every  case  dying  in  the  hospital.  It  includes  death  from 
accidental  causes,  such  as  pulmonary  embolus,  myocarditis,  and 
a  number  of  patients  dying  from  chronic  conditions  occurring 
after  one  month;  one  died  from  chronic  nephritis  ten  weeks  after 
operation.  These  computations  are  an  injustice  to  the  statistics, 
but  eliminate  the  personal  equation. 

There  were  845  cholecystostomies,  with  a  mortality  of  2.13  per 
cent.  In  the  last  series  of  500  there  were  272  cholecystostomies, 
with  a  mortality  of  1.47  per  cent.  Two  of  these  were  sudden  deaths 
from  pulmonary  embolism. 

*Read  before  the  American  Surgical  Association,  June  1,  1906.  Reprinted 
from  "Annals  of  Surgery,"  August,  1906. 

452 


l.jOO    OI'DKATKJNS    ()\    (;.\  LL-HLAI)l)i;it    AM)     HILK-PABSAGKS       4.'>3 

l.(t()k(>(l  ;il  from  I  lie  slaiidjioiiiL  of  iiioii;ilily,  (•liolc<-y>lo.stoiiiy 
is  tlic  safcsl,  and  should  1k«  considered  tlic  iioiiual,  operation  for 
the  averagecil.se.  As  we  lia<l  Kiil  one  case  of  our  own  in  I  Ik-  entire 
series  of  l.>()0  o|)(>ralions  in  wliicli  <faii-stones  ref(»rnied  in  I  lie  ^^dl- 
l)ladd(>r,  this  cannot  he  taken  as  a  valid  objection  to  leaving  it  in 
sitii. 

There  are  some  conditions  in  which,  after  cholecystostomy, 
future  trouble  may  be  expected.  First,  in  all  those  cases  in  which 
the  cystic  duct  is  obstructed  by  a  stone  and  the  gall-bladder  takes 
no  part  in  the  biliary  circulation  (contains  no  bile),  other  things 
being  equal,  it  should  l)e  removed,  as  in  this  condition  we  lia\e  oc- 
casionally had  to  remove  it  secondarily  for  the  relief  of  mucous 
fistula  or  colics  due  to  obstructions  to  drainage  from  kinking  or 
stricture.  Second,  thick-walled  gall-bladders  which  have  become 
functionless  lead  to  a  suspicion  of  malignant  disease  and  should  be 
excised.  Several  times  we  have  unexpectedly  removed  what  proved 
to  be  an  early  carcinoma  of  the  gall-bladder.  One  such  patient 
is  now  alive — more  than  three  years. 

In  connection  with  common-duct  surgery  it  is  not  wise  to  re- 
move a  functionating  gall-bladder  unless  for  direct  indication. 
This  is  particularly  true  if  cholangitis  exists,  as  common-duct  cases 
more  often  require  a  secondary  operation  than  any  other,  and  the 
gall-bladder  not  only  affords  easy  drainage  and  enables  cholecyst- 
enterostomy  should  there  be  future  contraction  and  obstruction  of 
the  common  duct,  but  it  is  also  a  safe  guide  to  the  deep  ducts  if 
future  trouble  should  arise. 

As  to  permanency  of  cure:  Patients  upon  whom  we  have  per- 
formed cholecystostomies  have  remained  well,  expect  in  a  few 
instances  of  bad  selection  in  our  early  experience  in  which  cholecys- 
tectomy would  have  been  the  better  operation. 

The  operative  disability  after  cholecystostomy  was  brief.  A 
short  incision  witli  separation  of  the  fibers  of  the  rectus  muscle 
rendered  early  union  without  liernia  almost  a  certainty.  By  turn- 
ing in  the  cut  margins  of  the  gall-lihulder  about  the  tube  (Summers) 
in  a  similar  manner  to  the  Stamm-Kader  gastrostomy  the  bile  dis- 
charge stopped  promptly,  since  on  removal  of  the  tube  at  the  end 


454  ^TLLIA^SI   J.    MAYO 

of  the  week  the  peritoneal  surfaces  agglutinated.     The  average 

patient  was  up  in  twelve  days  and  left  the  hospital  within  two 

weeks. 

Cholectstectoimt 

There  was  a  total  of  319  cholecystectomies,  with  a  mortality 
of  3.13  per  cent.  In  the  cholecystectomies  in  the  last  series  of  500 
cases  the  mortahty  was  1.62  per  cent. 

Cholecystectomy  has  an  increasing  field  of  usefulness,  but  its 
increase  of  mortality,  although  sHght,  is  for  one  reason  or  another 
fairly  certain,  and  prevents  it  from  replacing  cholecystostomy.  At 
the  same  time,  where  the  circumstances  permit  easy  removal  of 
the  gall-bladder  and  the  disease  is  confined  entirely  to  this  organ, 
it  is  the  operation  we  most  commonly  perform  even  in  cases  in 
which  cholecystostomy  would  answer  the  purpose.  But  if  the 
patient  is  very  obese  and  the  gall-bladder  has  a  broad  attachment 
to  the  Kver,  necessitating  prolongation  of  the  incision  or  increased 
manipulation,  cholecystectomy  is  the  more  difficult  and  dangerous 
operation. 

The  permanence  of  cure  after  cholecystectomy  is,  of  course, 
absolute  when  the  disease  is  confined  to  the  gall-bladder.  In  the 
majority  of  cases  the  incision  was  made  nearly  if  not  quite  as 
short  as  for  cholecystostomy.  The  period  of  convalescence  was, 
therefore,  about  the  same.  In  a  few  cases  a  longer  incision  was  re- 
quired, adding  several  days  to  the  disability.  Verj^  rarely  was  a 
patient  in  the  hospital  for  more  than  fourteen  days. 

Operations  upon  the  Cosevion  Duct — 207  Cases 
The  operations  upon  the  common  duct,  so  far  as  the  mortalit}^ 
is  concerned,  can  be  di^'ided  into  four  groups,  although  this  ar- 
rangement is  more  or  less  artificial,  since  some  of  the  cases  are 
hard  to  classify. 

Group  1:  105  patients,  with  3  deaths, — 2.9  per  cent., — con- 
sisting of  those  patients  in  whom  gall-stones  were  present  in  the 
common  duct,  but  without  immediate  active  symptoms.  Jaun- 
dice was  moderate  or  not  present.  If  it  was  present,  the  obstruc- 
tion was  incomplete  or  intermittent  and  permitted  the  escape  of  a 


1500    OPERATIONS    ON    fJALL-ULADUKIl    AND     I5ILE-PASSAGES       455 

certain  umouiiL  of  bile  into  llie  intestine.  There  was  comparatively 
little  infection  of  the  ducts,  and  except  for  the  presence  of  mucus, 
the  bile' was  normal.  The  operation  under  such  circumstances 
was  simple  and  the  eonvaleseenoe  short,  the  patients  usually  being 
able  to  leave  the  liospital  within  fifteen  days.  The  cures  have  been 
permanent. 

Group  2:  61  patients,  with  10  deaths — 10  per  cent.  A  series 
of  cases  in  which  there  was  active  infection  not  only  in  the  common 
duct,  but  also  involving  the  ducts  of  the  liver.  Stones  were  usually 
present.  The  patients  not  only  had  jaundice,  but  suffered  from 
Charcot's  fever  (malarial  type,  irregular  chills,  followed  by  a 
temperature  of  from  103°  to  107°  F.,  passing  off  in  a  few  hours  with 
sweating),  pain  intermittent  and  most  marked  just  previous  to  the 
active  symptoms;  during  the  remissions  a  little  bile  passed  the 
obstruction,  relieving  the  liver.  Among  the  older  writers  this 
was  called  "remittent  bilious  fever."  The  added  infection  at  once 
introduced  an  element  of  grave  danger,  not  only  from  the  opera- 
tion, but  from  the  production  of  certain  complications  which  caused 
death  within  two  months. 

It  is  in  this  group  of  cases  that  hepatic  duct  stones  may  form ;  we 
have  seen  7  examples  of  this  condition.  The  infection  and  interfer- 
ence with  drainage  from  a  stone  formed  in  the  gall-bladder,  but  which 
had  passed  into  and  become  lodged  in  the  common  duct,  furnishes 
the  necessary  conditions  for  their  formation.  The  cholangitis  may 
subside  and  the  stones  reach  a  more  or  less  cjuiescent  state,  but 
after  removing  the  calculi  from  the  common  duct  others  which  have 
formed  in  the  hepatic  ducts  may  pass  into  the  common  duct,  to 
cause  future  trouble. 

Coincident  enlargements  in  the  head  of  the  pancreas  or  changes 
in  the  duct-wall  may  lead  to  secondary  stone  formation.  In  four 
instances  under  such  circumstances  we  have  seen  stones  reform  in 
the  common  duct  requiring  second  operations  after  periods  of  from 
one  to  five  years.  In  two  the  gall-bladder  had  been  removed  at 
the  primary  operation,  and  the  stones  were  too  large  to  come  down 
from  the  hepatic  ducts.  The  possibility  that  these  stones  had  as 
their  nuclei  hepatic  duct  calculi  cannot  be  denied  in  one  case,  but 


456  WILLIAM   J.    MAYO 

it  does  not  seem  possible  that  this  was  true  in  the  other  three.  In 
this  group  of  cases  inflammatory  diseases  of  the  pancreas  were 
often  found  associated. 

As  a  rule,  these  patients  were  in  the  hospital  from  three  to  four 
weeks. 

Group  3:  Complete  obstruction  of  the  common  duct;  29  cases 
and  10  deaths;  34  per  cent.  It  is  hardly  necessary  to  call  attention 
to  the  fact  that  formation  of  bile  is  only  one  of  the  functions  of  the 
liver,  and  that  a  patient  may  live  for  a  great  length  of  time  with 
nearly  if  not  quite  complete  obstruction  of  the  common  duct,  the 
necessary  amount  of  bile  being  absorbed  by  the  blood  and  elim- 
inated with  the  urine,  perspiration,  etc.  In  Group  1  we  found  the 
bile  comparatively  healthy,  containing  only  a  moderate  amount 
of  mucus.  In  Group  2  the  bile  was  darker,  containing  a  large 
amount  of  mucus  and  often  showing  colon  bacillus  on  culture.  The 
third  group  showed  almost  no  bile  in  the  ducts,  and  the  little 
present  was  thin  and  of  a  dark,  spinach-green  color,  or  in 
the  worst  cases  a  condition  of  complete  acholia  was  manifest,  the 
ducts  being  filled  with  a  clear,  colorless,  mucoid  secretion.  The 
patients'  general  condition  was  extremely  poor,  pulse  feeble  and 
rapid,  and  in  the  long-standing  cases  edema  of  the  feet  and 
free,  bile-stained  fluid  in  the  peritoneal  cavity.  Albumin  and  casts 
in  the  urine  and  other  evidences  of  extreme  toxemia  were  usually 
manifest.  The  operative  mortality  in  this  group  during  the  period 
of  complete  obstruction  was  very  high — 34  per  cent.  This  included 
deaths  from  early  and  late  complications.  Acute  obstructions  of 
this  type,  when  accompanied  by  evidences  of  infection,  were  es- 
pecially fatal,  and  since  acute  obstruction  from  stone  is  seldom 
permanent,  it  is  often  wise  to  wait  for  a  period  of  remission  before 
operation.  It  frequently  happens  that  the  duct  will  dilate  suffi- 
ciently in  the  early  stages  to  permit  some  relief  of  the  symptoms, 
and  this  is  the  time  to  interfere.  Later  the  inflammatory  products 
in  the  duct-wall  may  contract  down  upon  the  stone,  giving  rise  to 
permanent  obstruction.  In  a  few  instances  of  complete  obstruc- 
tion which  came  on  suddenly  and  which  remained  without  tem- 
porary remission  of  symptoms,  spontaneous  cure  by  sloughing  of 


1500    OPERATIONS    OX    (JAr-L-HLADDKIt    AND    UILP>PAS.SAGES      457 

the  stone  into  the  intestine  took  jilace.  We  have  seen  4  such  ex- 
amples. In  each,  after  years  of  typical  gall-stone  symptoms,  there 
was  sudden  and  complete  obstructive  jaundice.  In  2  there  was  a 
steady  temperature,  and  in  all  4  there  was  a  {)eculiar  rigidity  of  the 
upper  abdomen.  After  from  six  to  twelve  weeks  of  acute  and 
severe  symptoms  the  patient  suddenly  became  relieved,  the  jaun- 
dice disappeared,  and  a  large  gall-stone  was  found  in  the  stool. 
Three  of  these  patients  were  subjected  to  operation  subsequently. 
In  all,  one  or  more  stones  were  found  in  the  gall-l)ladder  or  in  the 
adjacent  liver  border,  the  center  of  a  cicatricial  mass,  but  without 
communication  with  the  ])ile-tract,  the  common  duct  being  densely 
adherent  to  the  duodenum  at  the  site  of  perforation. 

The  most  common  causes  of  death  after  operation  in  this  group 
were  exhaustion  from  cholemia,  with  or  without  capillar^'  hemor- 
rhage, and  sudden  cessation  of  the  liver  function. 

All  the  patients  who  recovered  remained  well.  The  hospital 
disability  averaged  a  little  over  three  weeks. 

Group  4-"  This  group  concerned  malignant  disease — 12  cases, 
4  deaths — 333^  per  cent,  mortality.  Cancer  of  or  involving  the 
common  duct  occurs  in  two  forms:  First,  the  primary  tumor  of  the 
common  duct  or  papillie,  a  small,  hard,  grayish-white  mass,  with  a 
tendency  to  remain  localized  until  a  late  stage.  We  have  seen 
several  examples  and  have  had  two  primarily  successful  excisions, 
but  none  of  the  patients  lived  beyond  three  years.  Second,  com- 
mon-duct obstructions  from  carcinoma  extending  downward  from 
the  gall-bladder  and  cystic  duct,  or  from  cancer  of  the  head  of  the 
pancreas.  These  cases  are,  of  course,  inoperable,  and  even  an 
exploration  proved  fatal  in  several  instances. 

Relation  to  Pancreatitis 
One  of  the  most  interesting  problems  in  connection  with  surgery 
of  the  bile-tract  concerns  coincident  inflammations  of  the  pancreas. 
In  a  total  of  86  out  of  the  1500  cases  the  pancreas  was  involved  to 
an  extent  noticeable  on  examination.  Four  of  these  cases  were 
acute,  2  of  wliich  recovered  and  2  died.  Six  were  subacute;  2  of 
these  had  hemorrhagic  cysts;   5  recovered  and  1  died;   9  cancer,  5 


458  "U'lLLIAM   J.    MAYO 

deaths;  67  had  chronic  pancreatitis;  the  evidences  usually  con- 
sisted of  hard  nodules,  most  marked  in  the  head  of  the  pancreas 
and  near  the  common  duct.  Four  cases,  supposed  to  be  common- 
duct  obstruction  from  chronic  pancreatitis  alone,  were  shown  by 
subsequent  operation  to  have  had  an  undiscovered  stone  in  the 
ampulla.  In  a  few  cases  the  pancreatic  disease  apparently  was  not 
secondary  to  the  bile-tract. 

That  the  acute  forms  had  a  deleterious  effect  upon  the  patient 
is  unquestioned,  but  I  have  been  unable  to  separate  the  harm  done 
by  the  chronic  inflammations  from  the  essential  condition  in  the 
bile-tract,  and  I  do  not  believe  that  unless  it  was  obstructive  it  had 
a  decided  influence  on  the  prognosis. 

In  summing  up  the  causes  of  the  66  deaths,  10,  or  15  percent., 
were  accidental  and  could  be  eliminated.  The  largest  number  were 
due  to  cessation  of  liver  function,  usually  the  result  of  infections. 
Microscopic  examination  showing  destruction  of  the  epithelial 
elements  of  the  liver  and  often  fatty  degeneration.  Next  came  ex- 
haustion from  blood  changes  due  to  chronic  cholemia. 

The  mortality  and  the  complications  of  delay  placed  the  early 
operation  for  appendicitis  on  a  sound  surgical  footing.  To  remove 
the  disease  while  still  in  the  appendix  and  before  its  rupture  in- 
volved the  abdominal  cavity  was  the  logical  conclusion. 

The  same  reasons  apply,  and  with  equal  force,  to  the  early 
operation  for  gaU-stone  disease.  Remove  the  disease  while  it  is 
still  in  the  gall-bladder,  and  a  mortality  of  from  1.47  per  cent, 
(cholecystostomy)  to  1.62  per  cent,  (cholecystectomy)  is  the  result. 
This  includes  death  from  accidental  causes,  acute  perforation,  and 
gross  infections.  Excluding  these  cases,  a  mortality  of  less  than 
1  per  cent,  can  be  shown. 

With  the  passage  of  the  stone  into  the  common  duct  we  no 
longer  have  a  localized  disease,  but  one  fraught  wdth  grave  dangers 
from  liver  infection  and  cholemia,  and  in  this  condition  nearly  1  in 
7  of  our  cases  came  to  operation,  while  1  in  25  developed  malignant 
disease  of  the  gall-bladder  or  bile-tract,  and  in  most  of  these  cases 
gall-stones  were  present.  In  other  words,  1  patient  in  6  had  al- 
lowed the  favorable  time  for  operation  to  go  by,  although  the  very 
large  majority  had  ample  warning  in  the  early  and  safe  stage. 


PANCREAS 


CASE  OF  ACUTE   PANCREATITIS   WITH    FAT 
NECROSIS— OPERATION:  RECOVERY* 

WILLIAM    J.    MAYO 


J.  C,  male,  aged  fifty-nine,  American,  was  admitted  to  St. 
Mary's  Hospital  on  June  11,  1901,  with  the  following  history: 

For  two  years  he  had  sufifered  from  attacks  of  indigestion  and 
at  times  had  refrained  from  eating  for  twenty-four  hours  or  more 
in  order  to  obtain  relief,  ^yhile  able  to  attend  to  his  professional 
duties  during  this  time  he  lost  '25  pounds  in  weight. 

On  June  -ith  he  was  suddenly  seized  with  agonizing  pain  in  the 
epigastrium,  accompanied  by  marked  symptoms  of  collapse,  re- 
cjuiring  anodynes  and  vigorous  stimulation.  Vomiting  and  retch- 
ing were  frequent.  The  abdomen  became  greatly  distended,  and 
symptoms  of  acute  obstruction  of  the  bowels  developed.  June 
5th  and  6th  the  condition  remained  about  the  same,  temperature 
ranging  from  100°  to  10^2°  F.,  pulse  from  06  to  120.  Hiccup  be- 
came most  distressing. 

The  bowels  acted  slightly  as  a  result  of  purgation  and  enemata, 
but  wathout  relief  to  the  abdominal  distention.  Beginning  on 
June  6th  the  stomach  was  washed  out  and  rectal  feeding  instituted, 
with  some  relief  to  the  acuteness  of  the  symptoms,  although  the 
main  features  were  practically  unchanged.  On  this  date  an  in- 
definite tumor  of  irregular  outline  could  be  detected  under  the  right 
rectus  above  the  umbilicus,  in  the  region  of  the  gall-bladder.  On 
June  7th  and  8th  his  condition  was  practically  unchanged,  the 
hiccup  and  extreme  nervous  unrest  being  most  marked. 

The  physical  examination  on  admission  to  the  hospital  re- 
vealed the  following: 

A  large,  heavy  man,  of  splendid  physique,  vital  organs  in  good 
condition  except  for  a  trace  of  albumin  in  the  urine.  The  ab- 
domen was  verj'  tympanitic.  To  the  right  of  tlie  umlnlicus,  and 
above  it,  was  an  irregular,  indefinite  mass,  apparently  the  size  of  a 

*Reprinted  from  "Jour.  Amer.  Med.  Assoc,"  January  11,  190^. 
401 


462  WILLIAM   J.    MAYO 

large  fist.  The  temperature  was  101°  to  102°  F.,  pulse,  120,  and 
of  poor  quality.  He  was  very  restless,  hiccuping  at  intervals,  and 
having  every  appearance  of  extreme  illness.  There  was  slight 
jaundice. 

Diagnosis:  Gangrenous  cholecystitis  with  probable  perforation. 
The  patient  was  operated  on  at  once.  The  abdomen  was  opened 
through  the  right  upper  rectus,  coming  directly  upon  a  greatly 
thickened  and  adherent  omentum,  which  was  infiltrated  with  little 
white  or  brownish  spots  from  the  size  of  a  hempseed  to  that  of  a 
pea  or  larger.  On  loosening  the  adhesions  some  bloody  fluid  es- 
caped from  the  peritoneal  cavity.  It  was  now  noticed  that  the 
mesentery  was  infiltrated  in  a  similar  manner.  The  peritoneum, 
while  reddened,  was  unaffected.  The  diagnosis  of  fat  necrosis  was 
e\adent. 

Raising  the  omentum  and  transverse  colon,  the  greatly  enlarged 
pancreas  could  be  felt  like  a  pudding  in  a  tight  sac.  With  a  small 
aspirating  needle  this  was  aspirated  in  several  places,  withdrawang 
only  bloody  fluid.  The  rectus  was  severed  laterally  and  a  search 
instituted  for  the  gall-bladder,  which  was  found  far  to  the  right  and 
wholly  unconnected  with  the  tumor  previously  detected.  The  gall- 
bladder was  greatly  thickened  and  contained  one  enormous  stone, 
the  size  of  a  small  hen's  egg,  also  some  mucopurulent  material. 
The  stone  was  removed,  and  a  large  rubber  drain  inserted  and 
sutured  to  the  opening  in  the  gall-bladder  with  a  catgut  suture,  in 
purse-string  fashion,  drawn  tightly  to  prevent  leakage.  The 
drain  was  brought  out  of  a  stab  wound  in  the  right  groin.  A  large 
wick  of  gauze  was  placed  along  with  the  tube  into  the  right  kidney 
pouch.  The  whole  of  the  anterior  wound  was  closed.  Time  of 
operation  was  forty-five  minutes. 

The  patient  was  placed  in  bed  in  extreme  shock,  with  restless- 
ness, muscle  twitching,  cold  perspiration,  etc.  Temporary  delir- 
ium developed  after  the  anesthesia  had  passed  away.  Atropin,  as 
advised  by  Crile  in  this  form  of  shock,  was  found  most  eflaca- 
cious.  Strychnin,  rectal  exhibition  of  saline  solutions,  etc.,  were 
also  resorted  to.  At  the  end  of  eighteen  hours  an  immense  drain- 
age through  the  rubber  gall-bladder  drain  commenced.  It  was  a 
bloody,  serous  fluid,  -udth  little  evidence  of  bile.  This  discharge 
was  very  irritating,  and  on  examination  showed  pancreatic  fluid 
and  bile.  The  quantity  was  so  great  as  to  saturate  a  large  dressing 
every  four  hours.  In  two  weeks  this  irritating  discharge  was 
gradually  replaced  by  bile  of  a  more  normal  appearance,  and  at  the 
end  of  four  weeks  the  fistula  closed.     The  patient,  while  in  a  most 


CASE  OF  ACUTE  PANCREATITIS  WITH  FAT  NECROSIS    463 

critical  condition  for  a  week,  slowly  regained  his  health,  leaving 
the  hospital  in  seven  weeks,  and  he  is  now  in  perfect  health,  up  to 
his  usual  weight,  and  can  eat  and  digest  normally. 

It  is  evident  in  this  case  that  the  gall-stone  had  been  the  cause 
of  a  cholangitis  which  extended  to  the  pancreatic  ducts,  with 
resultant  acute  pancreatitis  and  fat  necrosis.  The  free  drainage 
and  relief  of  tension  following  the  opening  of  the  gall-bladder 
checked  the  process  short  of  abscess  formation. 

The  fine  constitution  and  previous  exemplary  habits  of  the 
patient  were  great  factors  in  the  recovery. 


PANCREATIC  CYST* 

WILLIAM    J.    MAYO 


The  pathology  of  this  rare  affection  has  advanced  but  little 
since  1885,  when  Senn  ^^Tote  his  classic  paper  upon  the  "Surgery 
of  the  Pancreas."  However,  workers  in  many  fields  are  reporting 
cases  and  making  comments  upon  the  prominent  features  which 
characterize  the  disease,  and  out  of  the  growing  material  at  our 
disposal  more  exact  pancreatic  surgery  will  evolve.  The  following 
is  a  report  of  a  typical  case  of  pancreatic  cyst: 

Mrs.  J.  S.,  aged  twenty-eight  years;  married;  mother  of  one 
child,  aged  eighteen  months.  Admitted  to  St.  Mary's  Hospital 
September  30,  1893,  with  the  following  history: 

One  month  after  the  birth  of  her  child  she  first  noticed  a  tumor 
just  to  the  left  of  the  midline,  between  the  umbilicus  and  the  mar- 
gin of  the  left  costal  cartiLage.  The  enlargement  gradually  in- 
creased in  si^e,  gi^'ing  rise  to  a  feehng  of  pressure  and  weight; 
during  the  past  four  months  it  has  grown  rapidly,  is  more  painful, 
and  cohcs  or  cehac  neuralgias  are  of  frequent  occurrence. 

There  is  marked  digestive  disturbance,  partly  due,  no  doubt, 
to  the  fact  that  she  is  two  and  one-half  months  pregnant  at  the 
present  time.  Her  general  health  is  faihng,  and  she  has  lost  15 
pounds  in  weight.  Physical  examination  reveals  a  smooth, 
rounded,  somewhat  elastic  tumor  in  the  left  hypochondriac  region, 
the  size  of  a  child's  head,  slightly  movable  in  a  direction  toward 
the  umbilicus.  Tumor  of  the  spleen  was  easily  excluded,  as  there 
was  an  intestinal  percussion-note  to  be  obtained  anterior  and  exter- 
nal to  the  enlargement,  showing  it  to  be  retroperitoneal  in  origin. 
Renal  cyst  from  the  upper  part  of  left  kidney  was  ruled  out  with 
more  difficulty.  The  urine  was  normal,  and  there  was  no  indica- 
tion of  urinary  disturbance  whatever.     Insufflation  of  the  colon 

♦Reprinted  from  "Medical  Record,"  February  10,  1894,  pp.  168,  169. 

464 


PANCREATIC   CYST  465 

witli  air  by  the  rectum  sliowcd  tliat  the  (Icsccndin^  colon  passed 
external  to  the  tumor,  hetwecn  it  and  the  h)in,  and  that  the  trans- 
verse colon  lay  just  below  it,  while  the  stonuich  percussion-note 
was  immediately  above.  A  diagnosis  of  jjancreatic  cyst  was  made 
by  exclusion,  admitting,  however,  of  a  possibility  of  cyst  of  the 
u{)per  part  of  the  mesentery  or  hydatid. 

On  October  15,  18I)'5,  an  incision  was  made  in  the  median  line 
above  the  umbilicus.  The  tumor  was  found  to  lay  between  the 
stomach  and  the  colon,  under  the  omentum,  but  too  far  to  the 
left  to  be  fixed  in  the  opening.  A  second  incision  was  made  in  the 
left  semilunar  line,  from  the  ninth  costal  cartilage  downward;  the 
gastrocolic  omentum  under  which  the  tumor  presented  was 
stitched  to  the  parietal  peritoneum  and  to  the  tumor-wall,  and  the 
cyst  opened  and  drained  of  about  one  quart  of  straw-colored  pan- 
creatic fluid  of  the  consistence  of  syrup.  Tubular  drainage  was 
established,  with  definite  healing  in  five  weeks.  The  course  of  the 
pregnancy  was  uninterrupted. 


VOL.  I — 30 


THE  SURGICAL  ASPECTS  OF  PANCREATITIS* 

WILLIAM    J.    MAYO 


In  1879  Balzer  described  acute  pancreatitis  in  association  with 
fat  necrosis.  Little  attention  was  attracted  to  the  subject,  how- 
ever, and  it  was  not  until  ten  years  later,  when  Fitz  wrote  his 
papers  on  the  subject,  that  the  medical  world  really  became 
aware  of  the  inflammatory  diseases  of  the  pancreas.  Fitz  soon 
after  pointed  out  the  fact  that  many  supposed  cysts  of  the 
pancreas  due  to  traumatism  were  really  accumulations  of  fluid  in 
the  lesser  cavity  of  the  peritoneum  and  in  the  omental  bursse. 

A  proper  understanding  of  chronic  pancreatitis  is  largely  due 
to  Robson,  who  first  noted  the  condition  in  connection  with  his 
operative  work  upon  the  biliary  tract.  In  fact,  the  surgical  study 
of  the  inflammatory  diseases  of  the  pancreas  may  be  said  to  be  the 
result  of  an  inquiry  into  the  causation  of  some  of  the  complications 
of  gall-stone  disease.  The  reason  for  this  depends  upon  certain 
anatomic  facts.  Brewer,  discussing  the  question  from  this  stand- 
point, calls  attention  to  the  embryologic  development  of  the  organ. 
The  pancreas  is  a  racemose  gland  without  a  firm  capsule,  its  pro- 
tected situation  defending  it  from  injury.  It  is  originally  formed 
of  two  offshoots  from  the  intestinal  tube,  each  having  a  duct  com- 
municating with  the  intestine.  The  two  buds  soon  coalesce,  the 
upper  channel,  known  as  Santorini's  duct,  becomes  obsolete,  and 
the  inferior,  or  duct  of  Wirsung,  carries  on  the  function.  Later 
investigations  show  that  the  duct  of  Santorini  is  not  usually  com- 
pletely closed,  although  it  is  ordinarily  functionless.     Schirmer 

*Read  at  the  Fifty-third  Annual  Meeting  of  the  American  Medical  Association, 
in  the  Section  on  Surgery  and  Anatomy,  and  approved  for  publication  by  the 
Executive  Committee:  Drs.  H.  O.  \Yalker,  A.  J.  Ochsner,  and  DeForest  Willard. 
Reprinted  from  "Jour.  Amer.  Med.  Assoc,"  October  4,  1902. 

466 


THE   SURGICAL   ASPECTS   OF   PANCREATITIS  407 

found,  ill  only  two  out  of  !().>  cadavers,  that  tliis  duct  was  al)sont, 
and  in  53  it  was  capal)le  of  carrying  the  entire  secretion  of  the  ^datid 
tJirough  its  intestinal  orifice,  which  is  situated  al)Out  13^  inches 
al)ovc  tile  oi)ening  of  the  pancreatic  duct  of  Wirsung.  It  is  to  be 
noted  that  as  the  pancreas  develops  it  is  completely  surrounded  by 
peritoneum,  the  posterior  layer  in  later  life  becoming  infiltrated 
with  fat,  changing  its  character,  and  aiding  to  account  for  the  direc- 
tion of  diffusion  of  material  escaping  from  the  pancreas.  The 
common  duct  of  the  liver  passes  around  the  head  of  the  pancreas, 
between  it  and  the  second  part  of  the  duodenum.  For  V/2  inches 
the  common  duct  lies  fused  or  in  close  contact  with  the  main  pan- 
creatic duct,  and  in  the  sulimucous  tissue  joins  with  it,  forming  the 
ampulla  of  Vater.  The  joint  opening  on  the  duodenal  surface  is 
situated  4  inches  below  the  pj'lorus. 

It  is  easily  seen  that  a  gall-stone  may  obstruct  the  common 
intestinal  orifice  without  blocking  the  pancreatic  duct,  or  at  any 
point  in  the  lower  13^  inches  of  the  common  duct  may  exert  in- 
jurious pressure  upon  the  pancreatic  duct,  or  a  stone  may  occlude 
it  entirely  at  the  diverticulum  of  Vater,  thus  explaining  the  etio- 
logic  relationship  existing  between  pancreatitis  and  gall-stone 
disease. 

This  brings  us  to  the  effect  of  tliis  pressure  on  the  pancreas. 
Hildebrand  experimentally  ligated  the  pancreatic  duct,  and  the 
result  was  acute  pancreatitis,  usually  of  the  hemorrhagic  type,  w  ith 
or  without  fat  necrosis.  Oj^ie  repeated  Hildebrand's  experiments 
with  the  same  results.  He  also  found  that  injecting  the  pancreas 
with  irritating  fluids  through  the  duct  would  produce  acute  pan- 
creatitis, and  in  Halsted's  case  the  postmortem  examination  re- 
vealed the  fact  that  a  stone  at  the  papilla  had  obstructed  the  open- 
ing so  that  bile  had  passed  throughout  the  pancreatic  ducts,  caus- 
ing the  fatal  pancreatitis.  Evans,  in  one  case  of  fat  necrosis,  at 
autopsy  found  the  pancreas  stained  with  bile,  even  in  the  tail. 
Flexner,  in  experimental  work,  demonstrated  that  acute  pan- 
creatitis resulted  from  the  injection  into  the  ducts  of  many  sub- 
stances, such  as  dilute  gastric  juices  and  so  forth,  without  an  in- 
fection. 


468  WILLIAM   J.    MAYO 

He  also  produced  the  disease  with  various  bacterial  cultures 
which  he  injected  into  the  ducts.  In  this  connection  Brewer  also 
points  out  the  effect  of  the  passage  of  large  stones  through  the 
papilla  in  relaxing  the  sphincter  and  permitting  infections  from  the 
duodenum.  Robson,  in  his  operative  work,  found  20  cases  or  more 
in  which  chronic  pancreatitis  resulted  from  partial  obstructions  or 
infections  of  the  duct,  interfering  with  free  drainage.  The  patho- 
logic condition  present  was  a  chronic  interstitial  pancreatitis,  with 
enlargement  and  hardening  of  the  gland,  much  resembling  malig- 
nant disease.  This  enlargement  of  the  head  of  the  pancreas  com- 
presses the  common  duct  and  causes  jaundice. 

It  can  be  seen  that  a  gall-stone  obstructing  the  papilla  may 
cause  bile  to  pass  through  the  duct  of  Wirsung,  and  in  some  cases 
out  of  the  duct  of  Santorini,  resulting  in  pancreatitis,  or  the  main 
pancreatic  duct  may  be  obstructed  and  yet  allow  the  pancreas 
escape  by  reason  of  the  accessory  duct  of  Santorini.  Considering 
the  frequency  of  gall-stones  and  infections  of  the  liver-ducts  which 
must  affect  the  pancreatic  ducts  more  or  less,  biliary  calculi  occupy 
the  most  important  position  as  to  the  causation  of  pancreatitis, 
and  the  form  which  the  disease  takes  depends,  to  a  large  extent, 
on  the  amount  of  obstruction  and  the  degree  of  infection  or  chem- 
ical irritation  which  takes  place.  In  13  recently  reported  cases  of 
acute  pancreatitis  operated  on  gall-stones  were  found  in  10.  Pan- 
creatitis also  occurs  independent  of  gall-stone  disease  through  in- 
fections from  the  gastro-intestinal  tract,  as  during  the  course  of  a 
duodenitis,  gastric  ulcer,  or  cancer;  and  at  times  its  origin  is  in- 
trinsic, having  no  external  evidences  as  to  its  causation. 

Pancreatitis  has  been  divided  by  Robson  into  acute,  subacute, 
and  chronic.  The  knowledge  of  acute  pancreatitis  has  been  gained 
so  largely  from  postmortem  examination  that  we  recognize  only 
the  more  severe  grades  of  the  disease.  The  few  surgical  observa- 
tions with  recovery,  and  the  accumulations  of  fluid  of  pancreatic 
origin  due  to  traumatisms,  occurring  in  the  omental  bursa  in  con- 
nection with  certain  heretofore  unexplainable  complications  found 
during  operations  on  the  biliary  tract,  lead  to  the  belief  that  many 
cases  of  acute  pancreatitis  are  not  recognized  because  recovery  has 


Tin:   SURGICAL   ASPECTS   OF    PAN'CREATITIS  4G!> 

taken  i)lacc.  It  is  alto^'ctlier  prohahlc  that  this  fliscase  is  not  so 
fatal  as  our  limited  knowledge  of  the  subject  wouhl  lead  us  to  be- 
lieve. The  course  of  the  acute  form  is  so  often  marked  by  hemor- 
rhage into  and  about  the  j)an(reas  that  the  condition  has  been 
called  acute  hemorrhagic  pancreatitis  without  regard  to  whether 
or  not  hemorrhage  was  a  prominent  factor,  and  in  other  cases  fat 
necrosis  was  a  feature  so  important  that  no  reference  was  made  to 
the  pancreas  at  all. 

Acute  pancreatitis  often  follows  an  injury,  as  in  one  of  Robson's 
cases,  in  which  a  servant  fell  against  the  corner  of  a  table,  striking 
the  al)domen  over  the  pancreas,  and  died  in  forty-eight  hours. 
The  disease  is  ushered  in  by  the  most  acute  and  sudden  pain  in  the 
epigastric  region,  followed  with  profound  collapse.  The  abdomen 
becomes  distended  at  once,  and  this,  with  the  nausea  or  vomiting, 
may  lead  to  the  diagnosis  of  intestinal  obstruction.  Among  the 
special  symptoms  noted  are  "nervous  unrest"  (Halsted  and  Opie), 
"repeated  attacks  of  collapse"  (Fowler),  "lividity"  (Evans),  and 
"hiccup"  (Mayo). 

In  the  hemorrhagic  form  death  usually  follows  in  a  few  hours  or 
days.  The  indications  at  this  time  are  to  relieve  the  shock  and 
sustain  life.  If  the  patient  is  tided  over  these  acute  symptoms  and 
a  subacute  pancreatitis  is  established,  death  may  result  later  from 
infection  with  formation  of  abscess.  It  is  in  this  condition  that 
incision  and  drainage  may  aid  recovery,  as  in  cases  reported  by 
Fowler  and  others.  The  drainage  may  be  anterior,  through  a 
tube  ])rotected  by  gauze  packing,  or  a  large  posterior  incision  at 
the  left  costovertebral  angle,  as  recommended  by  Robson.  In  the 
few  successful  cases  reported  the  drainage  was  prolonged  for  weeks 
or  months. 

Fat  necrosis  is  the  most  interesting  phenomenon  connected  with 
acute  pancreatitis.  It  occurs  in  a  large  percentage  of  cases,  and 
may  coexist  with  the  hemorrhagic  form,  or  in  some  of  the  cases 
which  end  in  recovery  without  hemorrhage  or  infection,  as  in  the 
case  which  we  reported.*  The  symptoms  are  those  of  an  acute 
form  of  pancreatitis  with  repeated  attacks  of  shock  and  collapse, 
*"Jour.  Amcr.  Med.  Assoc,"  January  \i,  I90i. 


470  WILLIAM   J.    MAYO 

probably  as  new  foci  are  formed  by  fresh  leakage  from  the  pancreas. 
The  fat  necrosis  is  usually  limited  to  the  upper  abdominal  region, 
and  affects  the  omentum,  mesentery,  and  retroperitoneal  fat  by 
preference,  although  cases  have  been  reported  in  which  the  epi- 
cardial  fat  has  been  involved  and  even  the  bone-marrow.  In 
Beck's  case  the  peritoneum  was  attacked,  having  much  the  ap- 
pearance of  tuberculosis.  The  distribution  of  the  areas  involved 
is  hard  to  explain.  Is  it  due  to  intraperitoneal  leakage  with  ab- 
sorption through  the  lymphatics,  or  is  it  not  possible  that  the  de- 
velopment of  the  pancreas  as  an  intraperitoneal  organ  and  the 
fatty  conversion  of  the  posterior  layer  of  the  peritoneum 'may  be 
the  important  factor  in  the  diffusion  of  the  irritant.'^ 

The ■  appearance  of  fat  necrosis  is  characteristic:  Little  areas 
of  opaque  spots  scattered  throughout  the  fat,  of  a  whitish  or  brown- 
ish hue,  from  the  size  of  a  millet-seed  to  that  of  a  pea,  or  often  very 
much  larger.  The  pancreas  itself  may  be  so  slightly  affected  that 
the  condition  has  been  overlooked  upon  examination.  This  is  the 
most  reasonable  explanation  of  cases  reported  without  mention  of 
the  pancreas.  Why  does  injury  or  disease  of  the  pancreas  cause 
hemorrhage  and  fat  necrosis?  Robson's  observation  that  there  is 
a  greater  tendency  to  hemorrhage  in  cases  of  jaundice  complicated 
with  pancreatic  disease  has  been  confirmed  by  the  experience  of 
others,  and  it  is  probable  that  disarrangement  of  its  secretory  func- 
tion may  have  this  effect.  The  action  of  the  pancreatic  secretion 
upon  the  fats  is  to  split  the  fat-globules  into  fatty  acids  and  glycerin, 
and  it  has  been  thought  that  the  absorption  of  the  glycerin  may 
act  in  this  manner.  It  would  appear,  however,  that  the  amount  of 
glycerin  absorbed  would  be  too  small  to  account  for  the  phenom- 
enon. The  fatty  acids  unite  with  the  calcium  salts,  giving  rise  to 
the  opaque  spots  which  characterize  the  disease.  As  aids  to  diag- 
nosis, glycosuria,  fatty  stools,  lipuria,  and  so  forth  are  of  value,  but 
are  not  often  present,  and,  therefore,  if  not  found,  have  no  negative 
weight.  Mr.  Cammidge,  in  a  few  cases,  discovered  a  peculiar 
crystal  in  the  urine  which  he  has  described  (Robson) .  Opie  found 
steapsin  in  the  urine  obtained  after  death  in  one  case.  Walker 
points  out  that  the  absence  of  pancreatic  secretion  from  stools  is 
shown  by  a  pale  color  of  the  feces,  much  like  that  condition  which 


TIIK  SUI«;i(AI,   ASI'KCTS   OK   pan(kf:atitis  471 

i>  peculiar  lo  cliolemia.  Most  cases  have,  at  some  time,  a  rise  of 
leinperaliire,  and  as  a  cliolatij^itis  is  often  the  source  of  infection  in 
acute  pancreatitis,  diills  and  fever  with  sweating  may  l)e  expected 
in  this  chiss  of  cases.  In  29  cases  of  chronic  pancreatitis  which 
came  to  necropsy  at  Johns  Hopkins,  Opie  found  the  three  most  com- 
mon causes  to  be  pancreatic  calculi,  gall-stones  in  the  terminal 
portion  of  tiie  duct,  and  carcinoma,  and  he  notes  its  frequent  ap- 
pearance as  a  complication  of  cirrhosis  of  the  liver.  Glycosuria 
coming  on  late  in  the  course  of  liepatic  cirrhosis  is  suspicious  of 
interstitial  changes  in  the  pancreas.  In  the  diagnosis  of  the  chronic 
forms  of  pancreatitis  Thayer  says  that  the  feces  should  be  searched 
for  excess  of  fats  and  for  fragments  of  the  pancreas.  Evidence  of 
imperfect  digestion  of  albuminoitls,  as  shown  by  Sahli's  glutoid 
capsule,  he  also  believes  to  be  of  value. 

In  acute  and  subacute  pancreatitis  the  surgical  indications,  be- 
yond the  opening  and  draining  of  septic  accumulations  in  or  about 
the  pancreas,  would  be  the  removal  of  the  gall-stones,  if  present, 
and  the  establishment  of  free  drainage  through  the  gall-bladder, 
relieving  the  tension  and  aiding  the  secretions  to  escape.  This 
procedure  alone  resulted  in  the  recovery  of  the  case  reported  by 
Beck  and  in  our  case. 

The  most  important  diagnostic  feature  of  chronic  pancreatitis 
is  jaundice,  and  in  thin  subjects  the  enlarged  pancreas  may  be  felt. 
Frequently  a  distended  gall-bladder  can  be  palpated,  which  is  un- 
usual in  stone  obstructing  the  common  duct.  The  slow  course 
aids  in  differentiating  from  malignant  disease. 

The  treatment  of  chronic  pancreatitis  is  by  drainage,  and  this  is 
best  accomplished  by  way  of  the  gall-bladder.  We  have  had  7  well- 
marked  cases,  4  treated  by  cholecystostomy,  3  by  cholecystenteros- 
tomy;  the  anastomosis  was  made  twice  to  the  transverse  colon 
and  once  to  the  duodenum.  All  the  patients  recovered,  and  the 
ultimate  result  in  the  cases  in  which  the  transverse  colon  was  used 
was  as  good  as  with  the  duodenum.  It  is  sometimes  difficult  to 
make  a  satisfactory  anastomosis  between  the  gall-bladder  and 
duodenum  in  these  cases,  on  account  of  adhesions.  Cholecystos- 
tomy is  preferred  by  Robson,  but  the  prolonged  external  discharge 
is   a  cause  of   much  annoyance   to  the  patients. 


BIBLIOGRAPHIC  INDEX 


Abbe,  21,  22,  23,  24,  27,  29,  44,  85,  103, 

117,  333,  334,  387 
Adami,  230,  320,  413 
Albu,  199,  220 
Allen  (Dudley),  216 
Andrews,  40,  89,  127,  179,  300 
Annandale,  20 
Audisten,  201 
Audry,  12 
Auerbach,  317 


Bai.dt,  86,  102 

Balzer,  232,  466 

Beadles,  385 

Beck,  470,  471 

Behrend,  164 

Berg,  395 

Beraays,  25,  28,  37,  38,  47,  72,  75,  90, 

105,  110 
Berthold,  196,  244 
Bettman,  207 
Bevan,  101,  228,  247,  350,  382,  392,  411, 

424,  449 
Beyea,  184,  192,  193 
Billroth,  19,  27,  34,  37,  38,  40,  41,  75, 

107,  166,  170,  207,  214,  280,  282,  290, 

304 
Binnie,  100 
Bircher,  35,  38,  54,  92 
Blake,  258,  263,  275,  297 
Bland-Sutton,  72,  97,  100,  385 
Bloodgood,  117 
Boas,  52,  95 
Bobbs,  343 
Bond,  311,  321,  323 
Bramwell,  271 
Brandt,  48 
Braun,  56,  76,  112,  138 


Brewer,  235,  236,  425,  466,  468 
Brigham,  86,  105 
Brinton,  97,  196,  200,  224 
Bristow,  86,  97,  224 
Brunner,  239,  244,  268 
Bull,  34,  37,  38,  41,  48,  53,  71 
Butlin,  14,  37,  385,  388 


Cabot,  142 

Cammidge,  470 

Cannon,   184,  195,  241,  258,  263,  297, 

309,  311,  31-2 
Carey,  13 

Carle,  111,  138,  156,  250,  365,  403 
Carrel,  309 

Chlumsky,  108,  118,  147,  150 
Clark,  321 
Collins,  75 
Cone,  12 

Conner,  41,  86,  105 
Cordier,  154,  192 

Cour^-oisier,  232,  379,  384,  387,  443 
Cramer,  219,  220,  221 
Crile,  251,  309 
Cruveilhier,  181 

Cuneo,  187,  188,  210,  230,  284,  315 
Cunningham,  295,  309 
Curtis,  109 

Cushing,  82,  115,  117,  122,  213,  309,  319 
Czerny,  40,  91,  94,  102,  108,  113,  115, 

116,  151,  153,  161,  190,  228,  261 


Davis,  374,  399,  411 
Dawbarn,  192 
Deaver,  275 
Debove,  200,  225 
Dennis,  60,  109 


473 


474 


BIBLIOGRAPHIC   INDEX 


Dickinson,  88,  126,  322 

Dieulafoy,  182,  271 

Doyen,  76,  91,  112, 122, 251,  261,297,  319 

Dudgeon,  233 

Dunn,  201,  209,  225 

Duplant,  201 

Duret,  92 


Edes,  364,  365,  402 
Einhorn,  14,  98 
Eiselsberg,  156,  319 
Eisendrath,  89,  127,  382 
Elliot,  344,  345,  353,  424 
Evans,  467,  469 
Ewald,  13,  52 

Fagge,  340 

Fantino,  111,  156,  250 

Felitzet,  33 

Fenger,  20,  23,  38,  39,  45,  51,  53,  68,  91, 

100,  109,  113,  114,  165,  332,  339,  345, 

349,  361,  379,  412 
Ferguson,  288 
Ferrier,  39,  156,  390 
Fiedler,  196,  224 
Finlayson,  101 
Finney,   126,   127,   175,   189,   192,  2^7, 

242,  249,  254,  255,  256,  260,  270,  273, 

276,  304,  306 
Fitz,  232,  379,  466 
Fletcher,  26 
Flexner,  12,  467 
Foote,  179 
Ford,  320 

Fowler,  251,  252,  261,  322,  469 
Francine,  267,  268 
Frank  (Kendall),  13 
Frank,  20,  27,  29,  37,  40,  45,  69,  90,  109 
Frankel,  394 
Frankl-Hochwart,  199 
Futterer,  201,  209,  225 

Gaston,  334 
Gerhardt,  88,  125,  198 
Gerster,  16 


Goffe,  280 

Graham,  52,  64,  73,  163,  172,  201,  208. 

209,  225,  277,  285 
Graser,  27 
Greenough,  274 
Greiss,  196 
Grunfeld,  268 
Guillot,  115,  117 
Guinard,  107,  280 
Gunzburg,  52 
Gussenbauer,  20,  37,  71,  97,  99 


Haberkant,  99,  165,  209,  229,  280,  287 

Haberlin,  93,  228 

Hacker,  13,  14,  23,  37,  39,  45,  109,  111, 

137,  257 
Hagenback,  27 
Hahn,  39,  45 
Halsted,  95,  100,  104,  115,  165,  366,  369, 

403,  406,  448,  467,  469 
Hamilton,  81,  342 
Hanot,  362,  402 
Harley,  342 
Harrington,  319 
Harris,  349 
Hartley,  71 
Hartmann,  21,  175,  176,  187,  188,  199, 

201.  211,  213,  214,  217,  224,  276,  284, 

410 
Haslam,  73.  74 
Heidenhain,  110 
Heineke,  36,  38,  46,  53,  92,  144,  189. 

227,  249,  254,  277 
Hektoen,  72.  97 
Hemmeter,  94,  95,  97 
Heydenreich,  88 
Hildebrand,  467 
His,  318 
Hoegh,  352 
Homans,  447 
Howard.  267 
Huntington.  178,  236,  309 


Ingals,  12 

Israel,  98 


IMIJLIOCUAIMIIC    INDKX 


413 


Jiicobi,  3.'} 
Jiikscli,  'H 
Jonu.s,  4K) 
Jonnesco,  .Sl;{ 
Jnslin,  27 i 

K.voKU,  !)(),  10!),  Mi,  45:$ 
Kjimmcrer,  27,  114 
Kirn.  Hi),  17!),  '.Ui,  f5!)() 

Kclir,  D.y.i,  ;5!)'i,  ;j!):j,  ;5!).j,  ;5!)!),  41 1,  41^, 

414,  4;e!) 
Keith,  ;5()!) 

Killing,  ij.'j,  157,  :nfi 

Kilyiiack,  3G4,  885,  401 

Kilhourne,  33G 

KochtT,  47,  56,  75,  70,  91,  98,  106,  107, 
108,  113,  114,  15.3,  166,  214,  io.'i,  259, 
276,  280,  282,  284,  288,  289,  315,  447 

Kiinif,',  11.  2C.  27,  34 

Kijrtc,  151,  156 

Kraske,  94 

Krauso,  3!)4 

Kriinlein,  161, 162, 212, 228, 282, 288, 291 

Kuhn,  95 

Kiimmell,  91,  108,  114,  115 

Kussmaul,  34,  52 

Kuster,  89,  127 

Landerer,  52 

Landois,  331 

Lange,  50 

I-ingcnbcck,  333,  345 

Lartigan,  320,  409,  440 

Laucnstein,  37 

Lavastine,  397 

Lcbert,  201,  209 

I^  Count,  368,  405 

lA'nnander,  440 

Leube,  88,  125,  174,  200,  225,  226 

Levy,  108 

Lindner.  100,  119 

Littlefield,  261 

Liilnner.  368 

Loreta,  36,  38,  46,  55,  74,  81,  92 

Lublinski,  12 


Lun<l.  184,  202.  210.  226,  271 
Lusthka,  122 


Mac  uoNALi),  S(i,  lu.",,  161.  162.  228 

Maekt'nzie.  26 

Maicr,  52 

Maisonneuvc,  25 

Malthe,  !)2.  lOS.  115.  126 

Martin  (Kdward),  110 

Marwedel,  109 

MaUi.s,  117 

Matti,  282 

Maury,  402 

Maydl,  41,  106,  107,  110,  161,  228 

Maylard,  14,  53,  72,  124.  141 

Mayo  (Charles  H.),  3, 10, 16, 23. 205, 217, 

227,  252,  253,  260,  261,  283,  289.  294. 
297,  301,  330,  429,  430,  438,  446,  452 

Mayo  (William  J.),  11,  .33,  43,  50,  62,  71. 
82,  9.3,  119,  121,  132,  139,  148,  161. 
169,  178,  194,  205,  207,  217,  218,  227, 

228,  231,  244,  246,  252,  253,  267,  279, 
283,  293,  299,  .301,  .308,  327,  330,  331, 
336,  346,  348,  355,  360,  364,  372,  384, 
392,  401,  407,  416,  421,  429,  430,  438. 
446,  452,  461,  464,  466,  469 

Mayo  Robson.     See  Robson 

McArdle,  162 

McArthur,  81 

McBumey,  334,  342,  365,  403,  412,  428 

McComiick,  41 

McCosh,  110 

McGill,  56 

McGraw,  157,  205,  259 

Meisenbach,  74 

Meissner,  317 

Meyer,  15,  26,  40,  55,  69,  76,  111,  115 
151,  159 

Micheaux,  88 

Mieczkowski,  394 

Mikulicz,  36,  .38,  46,  53,  85,  92.  100,  112, 
113,  115.  144.  15.3.  158,  162,  165.  175. 
186.  189,  1!)0.  204.  205.  209,  210,  213. 
217,  227,  228.  229.  230.  236.  249,  254, 
255,  260,  261,  271,  276,  277,  282,  284, 
287,  291,  315,  321,  394,  429 


476 


BIBLIOGRAPHIC   INDEX 


Millet,  172,  208,  225 

Miquot,  394 

Mitchel,  20 

Mixter,  26 

Miyoke,  394 

Moore,  93 

Morison,  161,  228,  344 

Moullin,  14 

Moynihan,  157,  187,  205,  211,  242,  244, 

250,  257,  261,  263,  264,  266,  268,  271, 

276,  315 
Mumford,  274,  295 
Mimro,  273,  275,  276 
Miirchison,  181 
Murphy,  80,  161, 179,  209,  222,  228,  229, 

235,  244,  266,  276,  285,  291,  311,  331, 

334,  395,  440 
Muscatello,  321 
Musser,  340,  342,  364,  385,  386,  388,  401, 

441 


Nasolloff,  21 
Naunyn,  336,  387,  394 
Netter,  394 
Nicolaysen,  88,  125 
Nisbet,  101 


OcHSNER,  21,  23,  29,  68,  75,  191,  209, 
236,  250,  252,  258,  273,  276,  293,  309, 
310,  395 

Ohage,  41 

Opie,  232,  236,  467,  469,  470,  471 

Osier,  34,  94,  196 

Pagenstecher,  297 

Park,  93 

Pawlow,  309 

Pean,  41,  75,  166,  280 

Pepper,  14 

Perman,  115 

Peterson,  159,  190,  261,  263,  264,  276 

Petit,  331 

Pilcher,  60 

Poncet,  12 

Postnikow,  41 


QUENTJ,  21 

Quincke,  397 


Rehx,  21 

Reinhardt,  198 

Remond,  200,  225 

Rendu,  402 

Ribbert,  368 

Richardson,  13, 16,  25,  27,  35,  38,  45,  85, 
86,  103,  105,  126,  168,  395 

Riedel,  340,  351,  392 

Robson,  70,  106,  107,  115,  142,  156,  158, 
165,  179,  183,  184,  211,  236,  240,  245, 
260,  276,  297,  315,  334,  340,  352,  365, 
366,  380,  387,  388,  395,  396,  402,  403, 
411,  412,  418,  424,  436,  466,  468,  469, 
470,  471 

Rockwitz,  56 

Rodman,  125,  176,  179,  193,  203,  227, 
242,  277,  305 

Rokitansky,  72,  181 

Rolleston,  364,  401,  402 

Rose,  35 

Rosenheim,  26,  52 

Roux,  117,  157,  158,  251,  261 

Rimipel,  12 

Russell,  101,  274 

Rutkowski,  112 

Rydygier,  161,  166,  228,  280 


Sahli,  471 

Sands,  15,  26 

Sargent,  323 

Schede,  27 

Schirmer,  466 

Schlatter,  71,  86,  105,  168 

Schroder,  336,  384 

Scott-Matolli,  251,  261 

Scudder,  289 

Sedillot,  39 

Senator,  26 

Senn,  12,  34,  39,  41,  46,  50,  71,  72,  76, 

91,  95,  113,  317,  464 
Shaw,  162 
Siegert,  384,  385 


BIBLIOGRAPHIC    INDEX 


477 


Smith  (Grcig).  41,  40,  ol,  53.  7i.  108. 

334,342 
Solis-Cohe;i,  44 
Sonnenljurg,  44 
Ssabancjew,  90,  109 
Stamm,  109,  45;$ 
Stark,  190 

SUirling,  309.  Sli,  313.  31G 
Stondel,  150 
Stirling,  331 
Stoerk.  14 

Summers,  378.  403,  453 
Sutton.     See  Bland-Sulton 
SjTnonds.  26 


Tait.  37.  05.  74.  333,  342.  350,  417 

Talma,  397 

Taylor.  35.  38,  196,  224,  225,  270 

Terrier,  95 

Testut,  295 

Thayer,  471 

Thornton,  334 

TifTany.  141 

Tillaux.  33 

TUlman,  13,  16 

Tinker,  126 

Trendelenburg,  27 

Treves,  41 

Tricomi,  200 

Trousseau,  16 

Tuholske,  108 


Uffelmann,  52 


Van  V'alzah,  93,  96,  101 

Virchow.  93,  228 

von  EiseLslxTg,  150,  319 

von  Hacker,  13,  14,  23,  37,  39,  45,  109, 

111,  137,  257 
voQ  Jaksch,  34 


Walker,  470 

Watson,  127,  137 

Watts,  204 

Webster,  336 

Weinlechner,  15 

Weir,  35,  30,  38,  50,  55,  76,  112,  115.  126. 

157,  179,  244,  250,  382 
Welch,  89,  93,  126,  196,  224,  228,  267. 

323,  337 
Wendt,  63 
White,  37,  65 
Winiwarter,  37.  71,  98,  99,  334,  345,  366, 

403 
Witzel,  23,  28,  37,  40,  45,  69,  89,  90,  109, 

110,  112,  113 
Wiiiaer,  40,  41,  57,  70,  111,  113,  132,  137 
Woolsey,  28,  240 


Zeeheise.v,  27 
Zenker,  12 


INDEX  OF  SUBJECTS 


Abbe's    string-saw     method     in    non- 
dilatable  cicatricial  stricture  of  esoph- 
agus, 21 
Abdomen,  upper,  association  of  surgical 
lesions  in,  231 
operations   on,   drainage   of   fluids 
in,  322 
securing  of  asepsis  in,  321 
Abdominal   operation,   gastric  disturb- 
ance after,  cause,  49 
Abscess,   subdiaphragmatic,   from   per- 
forated gastric  ulcer,  36 
Acid,  hydrochloric,  free,  absence  of,  in 
gastric  cancer,  73,  94 
lactic,  in  gastric  cancer,  74,  94 
Adenocarcinoma  of  stomach,  97 
Adenoma  of  pylorus,  72 
Adherent  omentum,  traction  of,  gastric 

distress  from,  34 
Adhesions  in  gastric  cancer,  99 

operation  in,  1C5,  209 
Adossement,  54,  60 
Air,  distention  of  stomach  with,  value 

in  diagnosis,  43 
Air-passages,  foreign  bodies  in,  3 
Alimentary  canal,  1 

Andrews    and    Eisendrath's    operation 
for  hemorrhage  from  gastric  ulcer, 
127 
Andrews'  method  of  gastrostomy,  40 
Anemia  in  gastric  ulcer,  222 
Anesthesia,    cocain,    in    operations    on 
stomach,  117 
in  operations  on  stomach,  117 
in  radical  operation  for  gastric  cancer, 
287 
Anesthetic  in   operations  on   stomach, 

83 
Antiperistalsis  in  large  intestine,  311 


Antrum,  pyloric,  anatomy  of,  314 

Asepsis,  securing  of,  in  operations  on 
upper  abdomen,  321 

Aspiraticjn,  blind,  of  gall-bladder,  dan- 
gers, 333 
pneumonia  after  operations  on  stom- 
ach, 83 

Atonic  dilatation  of  stomach  in  neuras- 
thenia, 176,  201,  272 

Auerbach's  plexus,  317 


Bacteria  in  bile,  320 
in  gall-bladder,  321 
in  gall-stones,  394 
in  intestine,  321 
in  liver,  320 
in  stomach,  122,  319 
Ball-valve  gall-stone,  361,  412 
Bernays'   method   of    cureting    gastric 

cancer,  47 
Bevans  incision  in  operations  on  gall- 
bladder, 350 
Bile,  bacteria  in,  320 

in  stomach  after  gastro-enterostomy, 
138,  293 
from  duodenal  ulcer,  250 
infection  of  gall-bladder  from,  421 
Bile-ducts,    cancer    of,    cholecystenter- 
ostomy  in,  414,  415 
frequency,  414 
common,  anatomy  of,  440 

and    duodenum,    anastomosis    be- 
tween, 446 
cancer  of,  364,  401 
etiologj-,  364,  401 
gall-stones  as  cause,  402 
jaundice  in,  402 
operation  in,  428 


479 


480 


INDEX   OF   SUBJECTS 


Bile-ducts,  common,  cancer  of,  pain  in, 
365,  402 
symptoms,  402 
treatment,  365,  366,  403 
duodenal  end,  stones  in,  method  of 

removing,  428 
obstruction  of,  report  of  operation 

for,  330 
operations  on,  mortality  from,  454 
operative  loss  of  continuity  of,  446 
reparative  power,  427 
stones  in,  339 

care  in  exploring,  418 
chronic  pancreatitis  in,  426 
jaundice  complicating,  361,  379 
operations  for,  378,  396,  411,  424 

hemorrhage  in,  425 
removal  of,  344,  345 
stricture  of,  report  of  operation  for, 

330 
surgerj'  of,  421 
cystic,  anatomy  of,  440 
stones  in,  338 

care  in  exploring,  417 
cholecystectomy  for,  422 
operations  for,  372,  373,  396 
removal  of,  344 
malignant  disease  of,  operation  in,  350 
operations  on,  372,  407 
after-care,  413 
disability  after,  453 
jaundice  as  cause  of  hemorrhage 

after,  380 
mortality  from,  452 
permanence  of  cure,  453 
Eobson's  technic,  424 
secondary,  413 
stones  outside  of,  operations  for,  374 
surgery  of,  348 
status,  392 
Bile-tract,  anatomy  of,  235 
Biliary  calculus.     See  Gall-siones. 
Bilious  fever,  remittent,  455 
Billroth's  method  of  closure   of  stump 
and  independent  gastrojejunostomy 
in    radical     operation    for    gastric 
cancer,  290 


Billroth's     method     of     resection     of 
stomach,  41 
operation  for  gastric  cancer,  166 
for   non-dilatable   cicatricial   stric- 
ture of  esophagus,  19 
Bircher's  gastrorrhaphy  in  pyloric  ob- 
struction, 54 
Bladder,   mucous   membrane,   removal 
of,  as  substitute  for  cholecystectomy, 
355 
Blood,  examination  of,  in  gastric  cancer, 
95,  286 
vomiting  of,  as  sign  of  gastric  injury, 
35 
Blood-supply  of  gall-bladder,  440 

of  stomach,  62,  121 
Blood-vessels  of  stomach,  314,  315 
Bougies  in  cicatricial  stricture  of  esopha- 
gus, 16 
Brandt's    operation    for    dilatation    of 

stomach,  48 
Bristow's  water-bottle  stomach,  97 
Bronchi,  foreign  bodies  in,  4 
Bronchopneumonia   after   gastro-enter- 

ostomy,  149 
Buckle,    open,    in    esophagus,    location 
with  Rontgen  rays,  10 
removal  of,  10 
Buttons  of  omentum,  34 

Cachexia,  cancerous,  73 

in  gastric  cancer,  64 
Calcium    chlorid    as    prophylactic    in 
hemorrhage  from  jaundice  in  opera- 
tions on  bile-passages,  380 
Calculus,  biliary.     See  Gall-stones. 
Canal,  alimentary,  1 
Cancer,  gastric.     See  Gastric  cancer. 
of    bile-ducts,    cholecystenterostomy 
in,  414,  415 
frequency,  414 
operation  in,  350 
of  common  bile-duct,  364,  401 
etiology,  364,  401 
gall-stones  as  cause,  402 
jaundice  in,  402 
operation  in,  428 


INDKX    OF    SI  ISJtXTS 


481 


CiiiictT    of    coniiiinii    liilc-diicl ,  |);iili    in, 
'Mh't,  iOi 
syiuploins,  Wi 
trciitfiK'iil,  :t(i,">,  ;{()(>.  M».'5 
of  diiodi'iuiin,  17!) 
of  gall-l)Iu(l(li'r.  .'Wl 

cliolecysleclouiy  in,  '.i'Ai,  tiHH 
cholecystentcrosloiiiy  for,  ;J81,  414, 

415 
diagnosis,  S86 

difrercniiiil,  .SH7 
fro((ncncy,  414 

fj.'ill-stones  as  cause,  '584,  411 
involving  liver,  .'$!)() 
jaundice  in,  iid'i,  .'5H7 
of  liver  and  gall-stones,  relation,  ;540 
of  pylorus,  98,  !)S 
frequency,  'M 

obstruction     from,     71.     See    also 
Pyloric  obstritclion,  iintlignanf. 
of  stomach.     See  (iuslric  cancer. 
Cancerous  cachexia,  73 
Carcinoma.     See  Cancer. 
Cardiac  extremity  of  stomach,  33 
orifice   of   stomach,    method    of   ex- 
ploring, 85 
obstruction,    Kader's    ojjeration 
in,  90 
Ssabanejew-Frank      operatioa 

in,  90 
surgical  treatment,  89 
Witzel's  operation  in,  89 
Catarrh,  stone-building,  393,  409 
Catarrhal  cholecystitis,  376 

jaundice,  3G3 
Cecocolic  sphincter,  310 
Cerebrosj)inal   nerves,   control  of,   over 

stomach,  317,  318 
Cholangitis,  infective,  oi)eration  in,  348 
Cholecystectomy,  349,  353,  355 
for  cancer  of  gall-bladder,  388 
for  gall-stones,  333,  345.  409,  410 
for  injuries  of  gall-bladder,  356 
for  malignant  disease  of  gall-bladder, 

356 
for  stones  in  cystic  duct,  42'2 
indications  for,  355 
VOL.  I — 31 


(  liolccN  ^trcloiiiy,   MiorLility  from,  433 
4.37,  45  I 

((crmanence  of  (lire  after,  451 

niiioval     of     muccjus    mi-mbrane    of 
gail-l)la<l(ler  as  substitute  fur,  350 
(  liolecystenlfTostomy,  350 

for  cancer  of  gall-bladder,  381 
and  bile-ducts.  414,  415 

for  chronic  pan<reatitis,  381 

for  gall-stones,  .345 

in  disease  of  common  bile-duct,  429 
(  iiolecystilis,  catarrhal,  ;{7(> 

cholecystotomy  in,  378 

chronic,  operation  in,  397 

gall-stones  from,  440 

operations  in,  375 

sui)purative,  370 
(holecystostomy.  causes  of  failure,  418 

for  gall-stones.  409,  410 

mortality  from,  4.33-437 

operati\c  disability  after,  453 
Cholecystotomy,  348 

for  gall-stones,  333,  342,  348 
drainage  in,  344 

ideal,  343,  350,  398,  409 
for  gall-stones,  409 

in  cholecystitis,  378 

in  gall-stones,  398 
Choledochotomy,  349 

for  gall-stones,  349 

mortality  from,  433-437 
Cholelithiasis.     See  Gall-stones. 
Cicatricial  stricture  of  esophagus,ll.  See 

also  Esophagus,  stricture  of,  cicatricial. 
Cirrhosis  of  liver,  jaundice  in,  36:2 
Cocain    anesthesia     in    operations    on 

stomach,  117 
Colic  in  diagnosis  of  gall-stones,  237 

in  gall-stones,  3.38,  408,  409,  441 
renal  colic  and,  differentiation,  441 

renal,  and  gall-stone  colic,  differentia- 
tion, 441 
Collapse  after  operation  for  malignant 
disease  in  abdomen,  114 

in  acute  pancreatitis,  409 
Comnu)n     bile-ihict.       See    Bile-ducts, 

common. 


482 


INDEX   OF    SUBJECTS 


Contraction    of    anastomotic    opening 
after  button  gastro-enterostomy,  115 
Cruveilhier's  acute  round  ulcer  of  stom- 
ach, 181 
Cureting    of    gastric   cancer    for    diag- 
nostic purposes,  95 
Cylindric-cell  cancer  of  stomach,  97 
Cyst  of  pancreas,  464 
Cystic  duct,  anatomy  of,  440 
stones  in,  338 

care  in  exploring,  417 
cholecystectomy  for,  422 
operations  for,  372,  373,  396 
removal  of,  344 


Davis'  method  of  drainage  in  gall-stone 

operations,  399 
Diet  after  operations  on  stomach,  117 
before  operations  on  stomach,  116 
potato,  for  foreign  bodies  in  stomach, 
35 
Dieulafoy's  mucous  erosion,  182,  271 
Dilatation,     atonic,     of     stomach,     in 
neurasthenia,  176,  201,  272 
gradual,    in    cicatricial    stricture    of 

esophagus,  16 
of  stomach,  128 

and  malignant  pyloric  obstruction, 

differentiation,  72 
Brandt's  operation  for,  48 
gastro-enterostomy  in,  131 
gastroplication  in,  131 
gastrotomy  for,  38 
method,  123 

not  of  organic  origin,  176,  201 
operation  in,  184 
pyloroplasty  in,  131 
results,  140 
surgery,  35,  38 
retrograde,   and  gastrotomy,   in  im- 
passable stricture  of  esophagus,  27 
Displacement    of    stomach,    effect    of 

weight  of  tumors,  34 
Distention    of    stomach    before    opera- 
tions on  stomach,  34 
method,  33 


Distention  of  stomach  with  air,   value 

of  diagnosis,  43 
Diverticulum    of  esophagus  and  cica- 
tricial strictm-e  of  esophagus,  differ- 
entiation, 14 
Doyen's     operation     to     prevent     re- 
gurgitant    vomiting     after     gastro- 
enterostomy, 112 
Drainage,  gastric,  144,  189 
in  gastric  ulcer,  226 
value  of,  in  neurotic  cases,  143 
hepaticus,  423 
in  chronic  pancreatitis,  471 
in    operations    for   removal    of    gall- 
stones, 344 
of  fluids  in  operations  on  upper  ab- 
domen, 322 
of  gall-bladder.  352 
Duodenum     and     common     bile-duct, 
anastomosis  between,  446 
cancer  of,  179 

diseases    of,     associated    with    gall- 
bladder disease,  179 
operations  on,  review  of  cases,  178 
perforation  of.  238,  239 
ulcer  of,  178.  223,  244 

acute  perforating,  operation  in.  247 
and     gastric    ulcer,    relative    fre- 
quency, 268,  269 
chronic,  267 

from  surgical  standpoint,  194 
gastro-enterostomy  in,  242 
pain  in,  198 
surgical  treatment,  301 
symptoms,  198 
classification,  270 
clinical,  270 
frequency,  244,  268 
gastro-enterostomy  in,  249,  302 

bile  in  stomach  after,  250 
hemorrhage    in,    operative    treat- 
ment, 248 
indurated,  270 
medical,  270 

treatment,  results  of,  274 
non-indurated,  270,  272 
operative  indications,  247 


INDEX   OF   SUBJECTS 


483 


DiKuli-num,  )il(<'r  of,  sex  froqueiHy,  iio 

suFf^ical  Ircatniont.  ii)i) 

symptoms,  iiti 

treatment,  surgical,  €99 

with  gall-hladder  ami  liver  compli- 
cations, operation  in,  €48 

with  gastric  complications,  opera- 
tion in,  €48 


Electhicity  in  non-dilatable  cicatricial 

stricture  of  esophagus,  €6 
Emaciation  in  gastric  cancer,  64 
Enlarged  glands  in  omentvmi  in  pyloric 

obstruction,  53 
Entero-anastomosis  after  gastro-enter- 
ostomy,  cases  illustrating,  154,  155 
in  regurgitant  vomiting  after  gastro- 
enterostomy, 138 
to  prevent  regurgitant  vomiting  after 
gastro-enterostomy,  ll!2 
Enterocholecystotomy    for    gall-stones, 

334 
Erosion  in  gastric  ulcer,  'JTl 

mucous,  of  stomach,  181,  IS'i 
Esophagectomy   in    non-dilatable   cica- 
tricial stricture  of  esophagus,  €0 
Esophagoscopy  in  stricture  of  esopha- 
gus, 14 
Esophagotomy,  external,  combined  with 
gastrotomy,  for  foreign  bodies  in 
esophagus,  8 
for  foreign  bodies,  7,  8 
in   non-dilatal)le   cicatricial   stricture 

of  esophagus,  19 
internal,   in   non-dilatable   cicatricial 
stricture  of  esophagus,  io 
Esophagus,  1 

diverticulum  of,  and  cicatricial  stric- 
ture of  esophagus,  diflferentiation, 
14 
foreign  bodies  in,  3,  (> 

and    foreign    bodies    in    trachea, 

differentiation,  3 
external  esophagotomy  for.  7,  8 
gastrotomy,   combined  with   ex- 
ternal esophagotomy  for,  8 


Esophagus,  foreign  biwlies  in,  illustrative 
cases,  8,  9 
instrumcntjj  for  removing,  7 
symptoms,  7 
treatment,  7 
open  buckle  in,  location  with  R5ntgen 
rays,  10 
removal,  10 
stricture  of,  cicatricial,  11 

and  esojjhageal  diverticula,  dif- 
ferentiation, 14 
bougies  in,  16 
diagnosis,  13 
dilatable,  treatment,  16 
esophagoscopy  in,  14 
etiology,  11 
general  character,  11 
impassable,  gastrotomy  and  ret- 
rograde dilatation  in,  €7 
gastrostomy  in,  €8 
treatment  of,  €6 
location,  13 

non-dilatable.   Abbe's  string-saw 
method  in,  £1 
Billroth's  operation  in,  19 
electricity  in,  €6 
esophagectomy  in,  20 
Gussenbauer's  operation  in,  €0 
internal  esophagotomy  in,  25 
Ochsner's  operation  in,  €1,  €4 
treatment,  19 
prognosis,  14 
treatment,  16 
congenital,  13 
fibrous.  \i 
simple,  12,  13 
ulceration     of,     cicatricial     stricture 
from,  11,  12 
Ether  anesthesia   in  radical   operation 

for  gastric  cancer,  287 
Excision  in  gastric  ulcer.  126.176.203.304 
Exhaustion    after    gastro-enterostomy, 

148 
Exploration    in    radical    operation    for 

gastric  cancer,  287 
Exploratory   operations   in   diseases   of 
stomach,  84,  123,  124,  141 


484 


INDEX   or    SUBJECTS 


Exploratory  operations  in  gastric  cancer, 
64,  65,  10-2,  16-2,  163,  17^2 
effects  of,  65 
ulcer,  20-2 
in  malignant   pyloric   obstruction, 
74 


Fat  necrosis  in  acute  pancreatitis,  461, 

469 
Fatal  suture  angle,  166,  214 
Feces,  gall-stones  in,  332,  444 
Feeding,    rectal,    after    operations    on 

stomach,  117 
Fenger's  ball-valve  stone,  361,  412 
incision  in  operations  on  stomach,  38 
method  of  gastrostomy,  39 
modification  of  Kocher's  method  of 
gastro-enterostomy,  113 
Fibrous  stricture  of  esophagus,  12 
Finney's  gastroduodenostomy,  192,  255 
in  gastric  ulcer,  204,  227,  242,  276, 
304 
Fish-hook  pj'lorus,  129 
Fissiue  ulcer  of  stomach,  181,  271 
Fistula,  gastric,  surgery  of,  35 

sutiu-e  in,  38 
Floating  gall-stones,  339 
Foregut,  organs  derived  from,  309 
Foreign  bodies  in  air-passages,  3 
in  bronchi,  4 
in  esophagus,  3,  6 

and   foreign   bodies    in    trachea, 

differentiation,  3 
external  esophagotomy  for,  7,  8 
gastrotomy    combined    with    ex- 
ternal esophagotomy  for,  8 
illustrative  cases,  8,  9 
instruments  for  remo\'ing,  7 
sj-mptoms,  7 
treatment,  7 
in  stomach,  gastrotomy  for,  38 
potato  diet  for,  35 
surgery,  35 
in  trachea,  3 

and  foreign  bodies  in  esophagus, 
differentiation,  3 


Foreign  bodies  in  trachea,  diagnosis,  4 

illustrative  cases,  6 

sj-mptoms,  3,  4 

prognosis,  4 

tracheotomy  for,  5 

treatment,  4 
i  Fowler's  position  in  septic  peritonitis, 
I       322 
Frank's  method  of  gastrostomy,  40 
Functions  of  stomach,  63 


Gall-bladder,  325 
anatomy  of,  235,  439 
aspiration  of,  blind,  dangers  of,  333 
bacteria  in,  321 

in  gall-stones,  394 
Sevan's  incision  in  operations  on,  350 
blood-supply  of,  440 
cancer  of,  384 

cholecystectomy  in,  356,  388 

cholecystenterostomy  for,  381,  414, 
415 

diagnosis,  386 
differential,  387 

frequency,  414 

gall-stones  as  cause,  384,  414 

involving  liver,  390 

jaundice  in,  362,  387 
disease,  diseases  of  duodeniun   asso- 
ciated with,  179 
drainage  of,  352 
ducts    of,    operations    on,    report    of 

seven  cases,  331,  335 
function  of,  331 
incision  in  operations  on,  350 
infection  of,  from  bile,  421 

in  gall-stones,  332,  412,  413 
injuries  of,  332 

cholecystectomy  in,  356 
mucous    membrane    of,    removal,    in 

gaU-stones,  399 
nerve-supply  of,  440 
operations  on,  372,  407 

after-care,  413 

classification,  333 

disabilitv  after,  453 


INDEX    OF   SUBJFXTS 


485 


(jiill-liladdcr,  opcr.it ions  cpii,  incision  for, 

jiiundice   as   caiiso   of   licniorrlia^i' 
after,  380 

inorlalitj'  from,  'i.'i'i 

perrnancncc  of  cure,  i.V.i 

report  of  seven  eases,  SIJl,  335 

secondary,  413 
I)elvis  of,  r,i5,  UO 
perforation  of,  ■i'.W,  '23!) 
rupture  of,  333 

Smith's  incision  in  o])erations  on,  3i2 
surgery  of,  348 

status,  392 
suture   of,    after   removal    of   stones, 
333,  334 

in  wound,  dangers,  343 
Tait's  incision  in  operations  on,  342, 

350 
Gall-stones,  330 

active,  operation  in,  395 
and  cancer  of  liver,  relation,  340 
as  cause  of  cancer  of  common  bile- 
duct,  402 
of  gall-I)lad(ler,  384,  414 
bacteria  in  fiall-hiadder  in,  304 
ball-valve,  3(il,  412 
cholecystectomy  for,   333,  345,   409, 

410 
cholecystenterostomy  for,  345 
cholecystitis  as  cause,  440 
cholecystostomy  for,  409,  410 
cholecystotomy    for,    333,    342,    348, 
398 

drainage  in,  344 
choledochotomy  for,  349 
chronic  pancreatitis  in,  412,  419 
colic  in,  338,  408,  409,  441 

diagnosis  of,  237 

renal  colic  and,  difTenntiation,  441 
complications  in,  395 
dangers   of   suturing   gall-bladder   in 

woinid  in  removal  of,  343 
diagnosis  of,  3,38,  438 

(litTerential.  340 
enterocholecystolomy  for,  334 
etiology  of,  336 


(jall-sloiics,  (ifl  li  stage,  s\(ii[)tonis  of,  443 
first  stage,  symptoms  of,  4  U 
floating,  339 

fourth  stiigc,  sympt«mis  of,  442 
frequency  of,  33(i,  392 
ideal  cholecystotomy  for,  409 
in  feces,  332,  444 
in  intestine,  341 

in  women,  reasons  for  frequency,  320 
incision  for,  342 

infection  of  gall-bladder  from,  322, 413 
jaundice  in,  332,  337,  300,  443,  444 
location  of,  372 
number  of,  337 

operation    for,    causes    of    failure    to 
cure,  410 

mortality  from,  240,  430 
outside;  bile-tract,  operations  for,  374 
pain  in,  338,  441 
pancreatitis  in,  412,  419,  457 
prognosis,  340 

removal  of  raucous  membrane  of  gall- 
bladder in,  399 
report  of  two  operations  for,  327 
second  stage,  symptoms  of,  441 
slumbering,  392,  408 
suture  of  gall-I)ladder  after  removal, 

333,  334 
tension  in,  395 

third  stage,  sj-mptoms  of,  442 
treatment  of,  341 

medical,  341 

surgical,  342 
typhoid  fever  as  cause,  377 
urine  in,  444 
Gas  pain,  319 
Gastrectasia,  forms  of,  128 
Gastrectomy,  40,  41 
Rillroth's  method,  41 
in  gastric  cancer,  104,  105,  108 
in  malignant  disease  of  stomach,  8(5 
partial,  41 

and  pylorectomy,  in  gastric  cancer, 
106 
Gastric  cancer,  93,  228 

absence  of  free  hydrochloric  acid  in, 
73.94 


486 


INDEX   OF   SUBJECTS 


Gastric  cancer,  adhesions  in,  99 
operation  in,  165,  209 

age  in,  93 

and  gastric  ulcer,  relation,  163,  201, 
209,  225,  277,  285 

Bernays'  method  of  cureting,  47 

Billroth's  operation  for,  166 

cachexia  in,  64 

checking  of,  after  exploratory  in- 
cision, 37 

collapse  after  operation  for,  114 

colloid  type,  97 

condition  of  patient  in,  curability 
depending  on,  101 

curability  of,  96 

ciu-eting    of,    for   diagnostic     pur- 
poses, 95 

cylindric-cell,  97 

diagnosis,  37,  63,  141,  163,  229,  284 
early,  94 

diagnostic  massage  in,  95 

disappearance  of,  after  exploratory 
incision,  37 

emaciation  in,  64 

examination  of  blood  in,  95,  286 

exploratory  operations  in,  64,  65, 
102,  162,  163,  172 
effects  of,  65 

extension  of,  operation  in,  165 
to  surrounding  structures,  cura- 
bility depending  on,  99 

fragments  in  stomach  contents  in, 
95 

frequency,  71 

gastrectomy  in,  86,  104,  105,  168 

gastro-enterostomy  in,  65,  110,  133, 
145 
anterior  method,  111 
mortality  from,  134 
posterior  method.  111 
prolongation  of  life  after,  291 
regurgitant  vomiting  after,  112 

gastrostomy  in,  108,  109 

Hacker's  gastrostomy  in,  109 
Hartmann's    incision    in,    opposite 

page  185 
histologic  structure,  71 


Gastric     cancer,    histologic     structure, 
cvu-ability  depending  on,  96 
history  in,  importance  of,  63,  73, 

163 
jejunostomy  in,  110 
Kader's  gastrostomy  in,  109 
Kocher's  operation  for,  166 

pylorectomy    and    partial    gas- 
trectomy in,  107 
lactic  acid  in,  74,  94 
lines  of  incision  in,  opposite  page 

185 
location  of,  curability  depending  on, 

97 
lymphatic  involvement  in,  99,  119, 
210 
operation  in,  165 
Marwedel's  gastrostomy  in,  109 
Mayo's  incision  in,opposite  page  185 
medullary,  97 
Moynihan's    incision    in,    opposite 

page  185 
operations  in,  184 

radical,  65 
pain  in,  64 
palliative  operations  in,    108,    110, 

291 
percentage  of  hemoglobin  in,  286 
progress  of,  93,  96 
pylorectomy  and  partial    gastrec- 
tomy in,  106 
pylorectomy  in,  66,  87,  166,  167 
pyloric  end,  frequency  of,  37 
radical    operation    for,     161,    166, 
228,  280 
after-care,  291 
anesthesia  in,  287 
exploration  in,  287 
freeing  greater  curvature,  288 
mobilization    of   lesser   curva- 
ture in,  287 
mortality  from,  280,  281 
Murphy's    proctoclysis    after, 

291 
recurrences  after,  161 
removal  of  diseased  structures, 
288 


INDKX;    OF   SUBJECTS 


487 


Gastric   cancer,    nulical    oix-raliuti    fur, 
restoration  of  fjastro-inlcstiniil 
canal,   liilirotii  No.  2 
inctliofi,  iiW 
Kochcr's  nictliod.  ^H!) 
results  of,  IG'i 
separation    of   pyloric   end    of 

stomach,  !288 
steps.  18(i,  iJ87 
suture  of  gastric  stump,  iSi) 
reduced  motor  power  of  stomach 

in,  94 
Robson's  incision  in,  opposite  page 

185 
scirrlms  type,  97 
Ssabanajcw-Fraiik  gastrostomy  in, 

109 
Stamm's  gastrostomy  in,  109 
surgery  of,  30 
status,  177 
surgical  treatment,  iiO,  279 

review  of,  280 
symptoms  of,  94 
test-meals  in,  64 
tests  of  stomacii-contents  for,  103, 

172 
treatment,  03,  0,3 
surgical,  279 
review  of,  280 
Tuholske's  operation  in,  108 
urine  in,  95 

value  of  test-meal  in  diagnosis  of,  43 
vomiting  in,  04,  94 
von     Hacker's     gastrostomy     in, 

109 
Witzd's  gastrostomy  in,  109 
diseases,  diagnosis,  33 
disturbances     acting     from     within 
stomach,  causes,  62,  69 
after  abdominal  operation,  cause, 

49 
from  omental  hernia,  48,  69,  70 
from  traction  iif  adherent  omentum, 
34 
drainage.  144,  189 
in  gastric  ulcer,  226 
value  of,  in  neurotic  cases,  143 


Gastric     incjtility,     inlcrfiniice     with, 
273 
myasthenia,  130 
tetany,  220 

in  gastric  ulcer,  199 
ulcer,  124,  221 
acute,  173 

and   duodenal    ulcer,    relative    fre- 
quency, 268,  269 
antl   gastric  cancer,    relation,    103, 

201,  209,  225,  277.  285 
anemia  in,  222 
chronic,  173,  267 

from  surgical  standpoint,  194 

I)ain  in,  197 

prognosis  of,  225 

pyloric  stenosis  from,  199 

Robson's,  183 

surgical  treatment,  301 

symptoms  of,  197 
classification  of,  180,  181,  270 
clinical,  270 
complications,  226 
diagnosis,  36,  125,  141,  224 
distortion    and    contraction    after 

healing,  89 
erosion,  271 
etiology,  195,  222 
excision  in,  126,  176,  203,  304 
exploratory  operation  in,  202 
Finney's  pyloroplasty  in,  227,  242, 

276,  304 
fissure,  181 
fissure-like.  271 
frequency.  195.  196.  267 
gastric  drainage  in.  226 

tetany  in,  199 
gastro-enterostomy  in,  125,  134,145, 
175,  203,  204,  227,  276,  302 

case  illustrating,  151 

complications  after.  154 
hemorrhage  from,  224 

Andrews  and   Eiscndrath's  oper- 
ation for,  127 

gastro-enterostomy  in.  127 

treatment,  89,  127 
surgical,  300 


488 


INDEX   OF   SUBJECTS 


Gastric  ulcer,  hour-glass  stomach  from, 

treatment,  127 
hyperchlorhydria  in,  222 
indurated,  270 
line  of  incision  in,  202 
opposite  page  183 
location  of,  184,  196,  224 
McGraw  ligature  operation  in,  205 
mechanical  injury  in,  223 
medical,  270 

treatment,  results  of,  274 
multiple,  224 
non-indurated,  270,  272 
number  of,  196 

obstruction    from,    gastro-enteros- 
tomy  in,  128 
pyloroplasty  for,  127 
treatment,  127 
operations  in,  180 

advisability,  273 
pain  in,  173,  223 
perforation  in,  88,  126 

results,  36 

surgical  treatment,  299,  300 

treatment,  89,  126 
pore-like,  181 
prognosis,  200,  225 
pyloric  obstruction  from,  50,  127 

spasm  in,  273 
pyloroplasty  in,  203,  227,  277 
Rodman's  operation  in,  203,  227, 

242,  277,  305 
round,  181 

acute,  181 

chronic,  181 
sentinel  lymph-glands  in  locating, 

184,  271 
sex  frequency,  196,  224 
surgical  treatment,    36,    88,     124, 
125,  173,  299 
indications  for,  225,  226 
symptoms,  173,  223 
tests  of  stomach-contents  in,  200 
treatment  of,  medical,  125 
results  of,  274 

surgical,  124,  125,  299 
vomiting  in,  224 


Gastroduodenostomy.  See  Pyloroplasty. 
Gastro-enterostomy,  145,  253,  256 
anterior  method,  137,  146,  150,  257 
bile  in  stomach  after,  138 
bronchopneumonia  after,  149 
complications  after,  148 
detachment  of  bowel  from  stomach 

after,  147,  149,  150 
entero-anastomosis  after,   cases  illus- 
trating, 154,  155 
exhaustion  after,  148 
for   gastric    ulcer,    case    illustrating, 

151 
in  benign  pyloric  obstruction,  136 
in  chronic  duodenal  ulcer,  242 
in  dilatation  of  stomach,  131 
in  gastric  cancer,  65,  110,  133,  145 
anterior  method.  111 
mortality  from,  134 
posterior  method.  111 
prolongation  of  life  after,  291 
regurgitant  vomiting  after,  112 
ulcer,  125,  134,  145,  175,  203,  204, 
227,  276 
complications  after,  154 
in  hemorrhage  from  gastric  ulcer,  127 
in  hour-glass  stomach,  137 
in  interference  with  mechanical  action 

of  stomach,  46 
in  malignant  pyloric  obstruction,  76 

cases,  79,  80 
in  obstruction  from  gastric  ulcer,  128 
in  pyloric  obstruction,  55,  56,  91 
cases  illustrating,  58,  59,  60 
in  ulcer  of  duodenum,  249 

bile  in  stomach  after,  250 
indications  for,  41,  132 
Kocher's  method,  113 

Fenger's  modification,  113 
length  of  jejunum  loop  in,  158 
lung  complications  after,  149 
McGraw  ligature  method,  259 
Mikulicz's  method,  190 
mortality  from,  148 
Moynihan's  method,  261 
Murphy  button  in,  68,  91,  110,  114, 
153,  258 


INDEX   OF   SUBJECTS 


480 


Gustro-cntcrosloiiiy,  Miirpliy  liultun  in, 
contraclion   of    iinaslDinolic  oixfi- 
ing  afUT,  115 
no-loop  method,  2G1,  203 

steps  of,  290 
opening  in,  location  of,  1"'<) 
posterior  nu'llioil,  l:J7,  IKi,  I.W,  257 
Postnikow's  met  hod,  41 
regurgitant  vnmitin;,'  .'iflcr,  138,    IIH, 
2o8 
Doyen's  oi)eralioii  for  preven- 
tion, 112 
entero-anastomosis  in,  138 
Rutkowski's  operation  for  pre- 
vention, 112 
Roux's  method,  201 
Senn's  metiiod,  113 
suture  method.  08,  91,  110,  114,  153, 
258,  2(i() 
contraction  of  anastomotic  open- 
ing after,  115 
technic  of,  293 

vicious  circle  after,  138,  140,  258 
AVoIHer's  method,  113 
Gastroiiepatie  omentum,  division  of,  in 

operations  on  stoTnaeli,  03 
Gastro-intestinal  canal,  embryology  of, 

309 
Gastrojejunostomy.     See     Gaslro-entcr- 

ostomy. 
Gastroplieation,  131 
Gastroptosis,  130,  143 
Gastrorriiaphy    in    gunshot    wound    of 
stomach,  09 
in  pyloric  obstruction,  54 
in  wounds  and  injuries,  38 
Gastrostomy,  Andrews'  method,  40 
Fenger's  method,  39 
for  feeding  purposes,  39 
Frank's  method,  40 
Hacker's  method,  39 

in  gastric  cancer,  109 
Ilahn's  method,  39 
in  gastric  cancer,  108,  109 
in  impassable  stricture  of  esophagus, 28 
in  mechanical  interference  with  action 
of  stomach,  45 


Gastrostomy,  Kadcr's,  in  gastric  cancer, 
10!) 
Marwcrlcl's,  in  gastric  cancer,  109 
Ssabanajcw-I"'rank,  in  gastric  cancer, 

109 
Stamm's,  in  gastric  cancer,  109 
Witzd's  method,  40 

in  gastric  cancer,  109 
Gastrotomy   and   retrograde    dilatation 
in  impassable  stricture  o(   esopha- 
gus, 27 
comliined    with    external    esophagot- 
omy  for  foreign  bodies   in   eso|)lia- 
gus,  8 
for  dilatation  of  stomach,  38 
for  foreign  bodies,  35,  38 
for     mechanical     interference     with 
action  of  stomach,  44,  45 
Gunshot  wound  of  liver,  340 

of  stomach,  gastrorriiaphy  in,  69 
Gussenbauer's  o[)cration  in  non-dilata- 
ble cicatricial  stricture  of  esophagus, 
20 


Hacker's  method  of  gastrostomy',  39 

in  gastric  cancer,  109 
Hahn's  method  of  gastrostomy,  39 
Hartmann's  incision  in  gastric  cancer, 
opposite  page  185 
point  of  election,  213 
pyloric  syndrome,  175,  199 
Heineke-Mikulicz     pyloroplasty.      See 

Pyloro  phi.it  y. 
Hemoglobin,  percentage  of,   in  gastric 

cancer,  280 
Hemorrhage  after   operations   on   gall- 
bladder and  bile-passages,  jaundice 
as  cause,  380 
control  of,   in   radical   operation  for 
cancer  of  pyloric  end  of  stomach, 
212 
from     gastric    ulcer,     Andrews     and 
Eisendrath's   operation   for, 
127 
gastro-enterostomy  in,  127 
treatment,  89,  127,  224,  300 


490 


INDEX   OF   SUBJECTS 


Hemorrhage  in   operation  for  stones  in 
common  bile-duct,  425 
in    ulcer    of    duodenum,     operative 
treatment,  248 
Hemorrhagic  pancreatitis,  acute,  469 
Hepatargia,  382,  397,  413 
Hepaticus  drainage,  423 
Hernia,  omental,  as  cause  of  gastric  dis- 
tress, 48 
gastric  distress  from,  69,  70 
Hiccup  in  acute  pancreatitis,  469 
Hindgut,  311 
History  in  gastric  cancer,  importance  of, 

63 
Hormones,  316 

Hour-glass  stomach  from  gastric  ulcer, 
treatment,  127 
gastro-enterostomy  in,  137 
resection  in,  305 
treatment,  90 
Hydrochloric  acid,  free,  absence  of,  in 

gastric  cancer,  73,  94 
Hyperchlorhydria,  131 
in  gastric  ulcer,  222 


Ideal  cholecystotomy,  343, 350, 398, 409 
Impassable  stricture  of  esophagus,  treat- 
ment, 26 
Incision,  Bevan's,  in  operations  on  gall- 
bladder, 350 
Fenger's,  in  operations  on  stomach,  38 
Hartmann's,  in  gastric  cancer,  oppo- 
site page  185 
in  operations  for  pyloric  obstruction, 
53 
on  gall-bladder,  342,  350 
on  stomach,  84 
line  of,  in  gastric  cancer,  opposite  page 
185 
ulcer,  202 

opposite  page  183 
Maylard's,  for  exploratory  examina- 
tion of  stomach,  124,  141 
modification,  141 
Mayo's,   in   gastric  cancer,   opposite 
page  185 


Incision,  Mikulicz's,   in  gastric  cancer, 
opposite  page  185 
Moynihan's,  in  gastric  cancer,  oppo- 
site page  185 
Robson's,  in  gastric  cancer,  opposite 

page  185 
Smith's,  in  operations  on  gall-bladder, 

342 
Tait's,  in  operations  on  gall-bladder, 

342,  350 
Tiffany's,  for  exploratory  examination 
of  stomach,  124,  141 
Intestine,  bacteria  in,  321 

detachment  of,  from  stomach,  after 

gastro-enterostomy,  147,  149,  150 
embryology  of,  309 
gall-stones  in,  341 
large,  antiperistalsis  in,  311 
small,  traction  weight  of,  producing 
funnel  shape  of  stomach,  opposite 
page  142 
vestibule  of,  234 
Irrigation  of  stomach  before  operations 
on  stomach,  34 


Jaboulat-Braun  operation  to  prevent 

regurgitant    vomiting    after    gastro- 
enterostomy, 112 
Jaundice  as  cause  of  hemorrhage  after 
operations  on  gall-bladder  and  bile- 
passages,  380 

catarrhal,  363 

in  cancer  of  common  bile-duct,  402 
of  gall-bladder,  362,  387 

in  chronic  pancreatitis,  471 

in  cirrhosis  of  liver,  362 

in  gall-stones,  332,  337,  360,  443,  444 

in  pancreatitis,  362 

in  stones  in  common  bile-duct,  379 

surgical  significance,  360 
Jejunostomy  in  gastric  cancer,  110 
Jonnesco's  pyloric  canal,  313 


Kader's  gastrostomy  in  gastric  cancer, 
109 


INDEX   OF   SUBJECTS 


491 


Kadcr's    operation    in    ol).striKlir)n     in 

cardiac  orifice  of  stomach,  90 
Kidney,  movable,  as  cause  of  pyloric 

obstruction,  5i 
Kocher's  method  of  gastro-entcro.st<jmy, 
li;3 
Fengers  modification,  113 
of   restoration   of   gastro-intcstinal 
canal  after  radical  operation  for 
gastric  cancer,  iH9 
operation  for  gastric  cancer,  IGG 
pylorectomy  and  partial  gastrectomy 
in  gastric  cancer,  107 


Laboratory  methods   in  diagnosis   of 
cancer  of  pyloric  end  of  stomach,  208 
Lactic  acid  in  gastric  cancer,  74,  94 
Lavage  of  stomach  before  gastric  opera- 
tions, 34,  115 
Ligament,  Treitz's,  265 
Liver,  325 

bacteria  in,  320 

cancer  of,  and  gall-stones,  relation,  340 

gall-bladder  involving,  390 
cirrhosis  of,  jaundice  in,  302 
common    duct    of.     See    Bile-ducts, 

common. 
gunshot  wound  of,  346 
Lividity  in  acute  pancreatitis,  469 
Loreta's  operation  in  pyloric  obstruc- 
tion, 55 
Lung  complications  after  operations  on 

stomach,  149 
Lymphatic     involvement      in      gastric 
cancer,  99,  119,  210 
operation  in,  165 
Lymph-glands  of  stomach,  85,  100,  185, 
210,  284,  315 
enlarged,    in    non-malignant     gas- 
tric disease,  53,  65,  85 
sentinel,  in  locating  gastric  ulcer, 
184,  271 


Malignant  disease  of  bile-ducts. 
Cancer  of  bile-ducts. 


See 


Malignant  of  gall-bladder.     See  Cancer 
of  gull-bladder . 
of  pylorus.     See  Cancer  oj  pylorus. 
of  stomach.     See  Gastric  cancer. 
obstruction  of  pylorus,  71.     See  also 
Pyloric  obstruction,  malignant. 
Marwcdcl's     gastrostomy     in     gastric 

cancer,  109 
Massage,  diagnostic,  in  gastric  cancer,  95 
Maylard's  incision  for  exploratory  ex- 
amination of  stomach,  124 
modification,  141 
Mayo's  incision  in  gastric  cancer,  op- 
posite page  185 
McGraw    ligature    method    of    gastro- 
enterostomy, 259 
operation  in  gastric  ulcer,  205 
Mechanical  interference  with  action  of 
stomach,  43 
gastro-enterostomy  in,  46 
gastrostomy  in,  45 
gastrotomy  in,  44,  45 
methods  of  diagnosis,  43 
omental  hernia  as  cause,  48 
pylorectomy  in,  47 
treatment,  43 
Medullary  cancer  of  stomach,  97 
Meissner's  plexus,  317 
Methyl-blue  in  malignant  pyloric  ob- 
struction, 75 
Mikulicz's   incision  in    gastric    cancer, 
opposite  page  185 
method  of  gastro-enterostomy,  190 
point  of  election,  210 
Motility,  gastric,  interference  with,  273 
Movable  kidney  as  cause  of  pyloric  ob- 
struction, 52 
Moynihan's  incision  in  gastric  cancer, 
opposite  page  185 
line,  203,  264 

method  of  gastro-enterostomy,  261 
Mucous  currents,  reverse,  311 
erosion  of  stomach,  181,  182 
membrane  of  gall-bladtier,   removal, 
as    substitute  for  cholecys- 
tectomy, 355 
in  gall-stones,  399 


492 


INDEX   OF   SUBJECTS 


Murchison's  pore-like  ulcer  of  stomach, 

181 
Murphy  button  in  gastro-enterostomy, 
68,  91,  110,  114,  153,  258,  260 
contraction  of  anastomotic  open- 
ing after,  115 
Murphy's     proctoclysis     after     radical 

operation  for  gastric  cancer,  291 
Muscular  action  of  stomach,  219 
Myasthenia,  gastric,  130 


Necrosis,   fat,    in   acute   pancreatitis, 
461,  469 

Nerves,  cerebrospinal,  control  of,  over 
stomach,  317,  318 
sympathetic,   control  of,   over  stom- 
ach, 318 

Nerve-supply  of  gall-bladder,  440 
of  stomach,  317 

Nervous  unrest  in  acute  pancreatitis,  469 

Neurasthenia,  atonic  dilatation  of  stom- 
ach in,  176,  201,  272 

New-growths  of  stomach,  surgical  treat- 
ment, 86 


Obstrtjctiox  from  gastric  ulcer,  gastro- 
enterostomy in,  128 
pyloroplasty  in,  127 
treatment,  127 
of  common  duct  of  liver,   report  of 
operation  for,  330 
Ochsner's    operation    in    non-dilatable 
cicatricial  stricture  of  esophagus,  21, 24 
Omental    hernia    as   cause    of     gastric 

distress,  48,  69,  70 
Omentum,  adherent,  traction  of,  gastric 
distress  from,  34 
buttons  of,  34 

enlarged  glands  in,  in  pyloric  obstruc- 
tion, 53 
gastrohepatic,  division  of,  in  opera- 
tions on  stomach,  63 
in  developing   phagocytosis  and    op- 
sonins, 322 
Opsonins,  omentum  in  developing,  322 


Pain,  gas,  319 

in  cancer  of  common  bile-duct,  365, 

402 
in  chronic  duodenal  ulcer,  198 

ulcer  of  stomach,  197 
in  gall-stones,  237,  338,  441 
in  gastric  cancer,  64 

ulcer,  173,  223 
Pancreas,  459 

anatomy  of,  235,  466 
cyst  of,  464 

effect  of  pressure  on,  467 
perforation  of,  240 
Pancreatitis,  acute,  468 

collapse  in,  469 

fat  necrosis  in,  461,  469 

hemorrhagic,  469 

hiccup  in,  469 

lividity  in,  469 

nervous  unrest  in,  469 

surgical  indications  in,  471 

symptoms  of,  469 

with  fat  necrosis,  461 
chronic,  468 

cholecystenterostomy  for,  381 

drainage  in,  471 

in  gall-stones,  412,  419 

in  stones  in  common  bile-duct,  426 

jaundice  in,  471 

treatment  of,  471 
complicating  gall-stones,  457 
in  gall-stones,  457 
jaundice  in,  362 
subacute,  468 

surgical  indications  in,  471 
surgical  aspects,  466 
Pelvis  of  gall-bladder,  235,  440 
Perforation,   acute,   in  duodenal  ulcer, 

operation  in,  247 
in  gastric  ulcer,  88,  126 

surgical  treatment,  299,  300 
treatment,  89,  126 
surgical,  299,  300 
of  duodenum,  238,  239 
of  gall-bladder,  238,  239 
of  gastric  ulcer,  results,  36 
of  pancreas,  240 


IM)i;\    OF    SrUJKfTS 


493 


I'crfonilioii  of  .sIdiiiiuIi,  T.W,  i'Mi 
rcriloiiilis,  scplic,  l"«»s\  Irr's  pcisilioii  in, 

slapliyfotocc'iis  allm.s  in,  'M'i 
I'lterson's  point  <>f  firctioii,  iJli.'J.  HH 
I'liagiK-ytosis,  onifntnin   in   ijcvclopinf,', 

liii 
I'Icxus,  Aiicrhacli's,  :5I7 

Mfis.siicr'.s,  lUT 
I'lifunioiiia    after   oixTatitins    on    stoni- 

acli,  Ki,  IIG 
I'oro-liki-  iili-iT  of  stoniacli,  ISl 
I'ostnikow's    nu'lliod     of     f,'a.stro-cnlt'r- 

osloniy,  41 
l'«)tato  diet  for  foreign  Ijodies  in  stom- 
ach, 35 
Proctoclysis,    Murpliy 's,    after    radical 

operation  for  gastric  cancer,  -2i)l 
I'ylcjrectoniy,  41 

and    gastroduodenostoniy    in    malig- 
nant pyloric  obstruction, 
75 
cases,  77.  78 
and    partial    gastrectomy    in    gastric 

cancer,  106 
IJillroth's  method,  41 
in  gastric  cancer,  GO,  87,  16C,  167 
in  malignant  pyloric  obstruction,  75 

cases,  77 
in  mechanical  interference  with  ac- 
tion of  stomach,  46 
in  pyloric  obstruction,  53 
Pyloric  antrum,  anatomy,  314 
canal  of  Jonnesco.  313 
end  of  stomach,  cancer  of,  adhesions 
in,  209 
extension  to  other  organs,  209 
laboratory    methods    of    diag- 
nosis, 208 
lymphatic  infection  in,  210 
radical  operation  for,  207 
after-treatment,  216 
control  of  hemorrhage,  212 
shock  in,  215 
steps,  211-217 
significance  of  palpable  tumor, 
208 


Pyloric  ob.stniclioii,  50 

Ix-iiign,  gastro-eiiterostoiiiy  in,  136 

operations  for,  67 
causes,  51) 
diagnosis,  52 

enlarged  omental  glands  in,  53 
from  gastric  ulcer,  50,  127 
from  movable  kidney,  52 
gastro-enterostomy  in,  55,  56,  01 

cases  illustrating,  58,  59,  60 
gastrorrhaphy  in,  54 
l>orcta's  operation  in,  55 
malignant,  and  dilatation  of  stom- 
ach, ditferentiation,  72 
diagnosis  of,  71 
exploratory  operation  in,  74 
gastro-enterostomy  in,  76 

cases,  79,  80 
methyl-blue  in,  75 
pylorectomy  and  gastroduoden- 
ostomy  in,  75 
cases,  77,  78 
surgical  treatment,  71,  75 
treatment  of,  non-operative,  74 

surgical,  71,  75 
^Yblfler's  operation  in,  76 
operations  for,  53 

incision  in,  53 
pylorectomy  in,  55 
pyloroplasty  in,  53,  92 

cases  illustrating,  58,  59 
results  of,  140 
surgical  treatment,  90 
valve  formation  in,  50,  51,  90,  128, 

142,  273 
vomiting  in,  64 
spasm,  129,  175,  183 
diagnosis,  142 
in  gastric  ulcer,  273 
physiology  of,  318 
pyloroplasty  in,  130 
stenosis  from  chronic  gastric  ulcer,  199 
syndrome,  175 
of  Hartmann,  199 
Pyloroplasty.  144,  189,  254 
Finney's,  192,  255 

in  gastric  ulcer,  204,  276,  304 


494 


INDEX    OF   SUBJECTS 


Pyloroplasty  in  dilatation  of  stomach, 

131 
in  gastric  ulcer,  203,  227,  277 
in  obstruction  from  gastric  ulcer,  127 
in  pyloric  obstruction,  53,  92 
cases  illustrating,  58,  59 

spasm,  130 
Pylorus,  adenoma  of,  72 
cancer  of,  98 

frequency,  37 

obstruction    from,     71.     See    also 

Pyloric  obstructioyi,  malignant. 
fish-hook,  129 
malignant  diseases  of,  93 
obstruction  of.   See  Pyloric  obstruction. 
sarcoma  of,  72 

spasm  of.     See  Pyloric  spasm. 
stricture  of,  50 

from  gastric  ulcer,  50 


Rectal    feeding    after    operations    on 

stomach,  117 
Regurgitant     vomiting     after     gastro- 
enterostomy, 112, 138,  148,  258 
Doyen's    operation    for    preven- 
tion, 112 
entero-anastomosis  in,  112,  138 
Rutkowski's   operation   for   pre- 
vention, 112 
Remittent  bilious  fever,  455 
Renal  colic  and  gall-stone  colic,  differ- 
entiation, 441 
Resection  oi  stomach,  40 
BUlroth's  method,  41 
Retrograde  dilatation  and  gastrotomy 
in  impassable  stricture  of  esophagus,  27 
Reverse  mucous  currents,  311 
Robson's  chronic  ulcer  of  stomach,  183 
incision   in   gastric   cancer,    opposite 

page  185 
technic  for  operations  on  bile-ducts, 
424 
Rodman's    operation   in   gastric   ulcer, 

203,  227,  242,  277,  305 
Rontgen  rays,  locating  open  buckle  in 
esophagus  with,  10 


Round  ulcer  of  stomach,  181 
acute,  181 
chronic,  181 
Roux's  method  of  gastro-enterostomy, 

261 
Rupture  of  gall-bladder,  333 
Rutkowski's   operation   to  prevent  re- 
gurgitant    vomiting     after     gastro- 
enterostomy, 112 


Saxtoeixi's  duct,  236,  466 

Sarcoma  of  pylorus,  72 

Scirrhus  of  stomach,  97 

Secretin,  316 

Senn's  method   of  gastro-enterostomy, 

113 
Sentinel  enlarged  lymph-nodes  in  locat- 
ing gastric  ulcer,  184,  271 
Septic  peritonitis.  Fowler's  position  in, 
322 
staphylococcus  albus  in,  323 
Shock  in  radical  operation  for  cancer  of 

stomach,  215 
Silk    sutures,     buried,     value    of,     86, 

166 
Silver  wire  sutures,  buried,  value  of,  86, 

166 
Slumbering  gall-stone,  392,  408 
Smith's  incision  in  operations  on   gall- 
bladder, 342 
Spasm,  pyloric,  129,  175,  183 
diagnosis  of,  142 
in  gastric  ulcer,  273 
physiology  of,  318 
pyloroplasty  in,  130 
Sphincter,  cecocolic,  310 
Ssabanejew-Frank  gastrostomy  in  gas- 
tric cancer,  109 
operation  in   obstruction   of   cardiac 
orifice  of  stomach,  90 
Stamm's  gastrostomy  in  gastric  cancer, 

109 
Staphylococcus  albus  in  septic  periton- 
itis, 323 
Stenosis.     See  Stricture. 
Stomach,  31 


INDEX   OF   HUBJECT8 


49.5 


Slomiuh,  adenoc'urciriuiiiii  of,  !J7 
ariiitoiny  of,  iiVZ,  'Mi 
and    associated    viscera,    surgery    of, 

j)riiici|)l'cs  iiiKlerlyiiij,',  .'iOS 
atcjiiic  (iiliitalioii,  in  nciirasllienia,  176, 

!eoi,  m 

bacteria  in,  122,  319 
bile  in,  after  gastro-cnterostoniy,  138, 
2!)3 
for  (iiioilciial  ulcer,  250 
blood-siipply  of,  02,  121 
blood-vessels  of,  31-t 
Hristow's  \vater-l)ottle,  07 
cancer  of.     See  Gastric  cancer. 
cardiac  orifice  of,  33 

method  of  exploring,  85 
obstruction,    Kadcr's    operation 
in,  90 
Ssabancjcw-Frank       operation 

in,  90 
surgical  treatment,  89 
^^  itzel's  operation  in,  89 
control  of  cerebrospinal  nerves  over, 
317,  318 
of  sympathetic  nerves  over,  318 
dilatation  of,  128 

and  malignant  pyloric  obstruction, 

differentiation,  72 
Brandt's  operation  for,  48 
gastro-cnterostomy  in,  131 
gastroplication  in,  131 
gastrotomy  for,  38 
method,  123 

not  of  organic  origin,  17fi,  201 
operation  in,  18-t 
pyloroplasty  in.  131 
results,  140 
surgery,  35,  38 
diseases  of,  diagnosis,  C2,  171 

exploratory  operations  in,  84,    123, 

124,  141 
non-malignant,  enlarged  lymphatic 

glands  in,  53,  C5,  85 
surgical  treatment,  82,  121 
treatment,  C2 
displacement  of,  effect  of  weight  of 
tumors,  34 


St<)ina<li,  disli-tilion    of,    beforr;    ojxTa- 
lions  (jn  st(jmacli,  3t 
method,  33 

with    air,    in    diagnosis    of    gastric 
cancer,  1(>4 
value  in  diagnosis,  43 
embryology  of,  309 
emptying  of,  at  time  of  operation,  124 
examination  of,  methods,  123 

test-meals  for,  123 
fistula  of,  surgery,  35 

suture  in,  38 
foreign  bodies  in,  gastrotomy  for,  38 
potato  diet  for,  35 
surgery,  35 
fragments  of  cancer  in,  95 
functions  of,  G3,  122,  140,  194,  236 
funnel   shape  of,   traction   weight  of 
small    bowel    producing,    opposite 
page  142 
gunshot  wound  of,  gastrorrhaphy  in, 

69 
hour-glass,  from  gastric  ulcer,  treat- 
ment, 127 
gastro-enterostomy  in,  137 
resection  in,  305 
treatment,  90 
injuries  of,  gastrorrhaphy  in,  38 

surgery,  35 
lavage  of,  before  gastric  {)perations, 
34,  115 
before  operations  on  stomach,  34 
lesser  curvature,  anatomy  of,  312 

blood-vessels  of,  315 
lymph-glands  of,   85,    100,    185,   210. 
284,  315 
enlarged,  in  non-malignant  gastric 

disease,  53,  65.  85 
sentinel,  in  locating  gastric  ulcer, 
184,  271 
malignant  disease  of.     See  Cancer  of 

stomach. 
mechanical  interference  with  action, 
43 
gastro-enterostomy  in,  46 
gastrostomy  in.  45 
gastrotomy  in,  44 


496 


INDEX    OF   SUBJECTS 


Stomach,  mechanical  interference  with 
action,  methods  of  diag- 
nosis, 43 
omental  hernia  as  cause,  48 
pylorectomy  in,  47 
treatment,  43 
method  of  emptying  contents,  312 

of  examination,  43,  44,  123 
motor  power  of,  reduced,  in  gastric 

cancer,  94 
mucous  erosion  of,  181,  182 
muscular  action  of,  219,  312 
nerve-supply  of,  317 
new  growths  of,  surgical  treatment,  86 
obstruction  of,  benign,  operations  for, 
67 
surgical  treatment,  89 
operations  on,  38,  180 
after-care,  117 
after-treatment,  34 
anesthesia  in,  83,  117 
aspiration  pneumonia  after,  83 
cocain  anesthesia  in,  117 
diet  after,  117 
diet  before,  116 

distention  of  stomach  before,  34 
division  of  gastrohepatic  omentum 

in,  63 
Fenger's  incision  in,  38 
incision  in,  84 
lavage  before,  34,  115 
lung  complications  after,  149 
preparation  of  patient  before,  77 
pneumonia  after,  116 
preparation  for,  115 
rectal  feeding  after,  117 
review  of  cases,  178 
outlining  of,  methods,  34,  123 
perforation  of,  238,  239 
physiologic  facts  concerning,  262 
physiology  of,  316 
position  of,  122 

preparation  of,  for  operation,  115 
pyloric  end,  cancer  of,  adhesions  in,  209 
extension  to  other  organs,  209 
laboratory  methods  of  diagno- 
sis, 208 


Stc»mach,  pyloric  end,  cancer  of,  lym- 
phatic infection  in,  210 
radical  operation  for,  207 
after-treatment,  216 
control     of     hemorrhage, 

212 
shock  in,  215 
steps,  211-217 
significance  of  palpable  tumor, 
208 
resection  of,  40 

Billroth's  method,  41 
scirrhus  of,  97 
storage  function,  312 
supersecretion  of,  131 
surgery  of,  33,  169 

principles  underlying,  308 
problems  relating  to,  139 
tramnatisms  of,  surgical  treatment,  92 
ulcer  of.    See  Gastric  ulcer. 
wounds  of,  gastrorrhaphy  in,  38 
surgery,  35 
Stomach-contents,  tests  of,  for  gastric 

cancer,  163,  172,  200 
Stomach-tube,  value  of,  172,  220 
Stone-building  catarrh,  393,  409 
Storage  function  of  stomach,  312 
Stricture,  cicatricial,  of  esophagus,  11 

and  esophageal  diverticula,  dif- 
ferentiation, 14 
bougies  in,  16 
diagnosis,  13 
dilatable,  treatment,  16 
esophagoscopy  in,  ,14 
etiology,  11 
general  character,  11 
impassable,  gastrostomy  in,  28 
gastrotomy     and     retrograde 

dilatation  in,  27 
treatment,  26 
location,  13 

non-dilatable.  Abbe's  string-saw 
method  in,  21 
Billroth's  operation  in,  19 
electricity  in,  26 
esophagectomy  in,  20 
Gussenbauer's  operation  in,  20 


INDEX    OF   SIBJECTS 


K)7 


Striclurt',      (•i<'atri(i;il,       iKni-dilal.iljIc, 
internal    csuplmgotoniy    in, 
25 
OcIisiut's  operation  in,  '21,  24 
treatment,  19 
prognosis,  14 
treatment,  15 
congenital,  of  esophagus,  13 
fil)rous,  of  esophagus,  12 
of  common   (kict   of   Hver,    report   of 

operation  for,  'i-2H 
of  pylorus.  .■>() 

from  gastric  ulcer,  .'iO,  199 
simple,  of  esophagus,  I '2,  13 
Subdiaphragmatic    abscess    from     i)er- 

forated  gastric  ulcer,  3G 
Supersecretion  of  stomach,  131 
Suppurative  cholecystitis,  376 
Suture  angle,  fatal,  IGG 
in  gastric  fistula,  38 
method  in  gastro-enterostomy,  08,  91, 
110,  114,  153.  258,  260 
contraction  of  anastomotic  open- 
ing after,  115 
of     gall-bladder     after     removal     of 
stones,  333,  334 
in  wound,  dangers,  343 
of  gastric  stump  after  radical  opera- 
tion for  cancer,  289 
Sutures,  silk,  buried,  value  of.  80,  106 

silver  wire,  buried,  value  of,  80,  166 
Sympathetic   nerves,    control   of,    over 
stomach,  318 


Tait's   incision   in   operations   on   gall- 
bladder, 342,  350 
Tension  in  gall-stones,  395 
Test-meals  in  examination  of  stomach, 
123 
in  gastric  cancer,  64 
value  of,  34 

in  diagnosis  of  gastric  cancer,  43 
Tetany,  gastric,  220 

in  gastric  ulcer,  199 
Tiffany's    incision    for   exploratory    ex- 
amination of  stouuieh,  124,  111 
32 


Trachea,  foreign  bodies  in,  3 

and  foreign  bodies  in  esophagus, 

ditrerentiation,  3 
diagnosis,  4 
illustrative  cases,  0 
prognosis,  4 
symptoms,  3,  4 
tracheotomy  for,  5 
treatnu'nt,  4 
Tracheotomy     for    foreign     bodies     in 

trachea,  5 
Traumatism  of  stomach,  surgical  treat- 
ment, 92 
Treitz's  ligament,  265 
Tuholske's  operation  in  gastric  cancer, 

108 
Tumors,  cfTect  of  weight,   in  displace- 
ment of  stomach,  34 
Typhoid  fever  as  cause  of  gall-stones, 
377 


I'lcer,  gastric.     See  Gastric  ulcer. 
of  duodenum,  178,  223,  244 

acute  perforating,  operation  in,  247 

and     gastric     ulcer,     relative     fre- 
quency, 268,  269 

chronic,  267 

from  surgical  standpoint,  194 
gastro-enterostomy  in,  242 
pain  in,  198 
surgical  treatment,  301 
symptoms,  198 

classification,  270 

clinical,  270 

frequency,  244,  268 

gastro-enterostomy  in,  249,  302 
bile  in  stonuich  after,  250 

hemorrhage    in,     operative     treat- 
ment, 248 

indurated,  270 

medical,  270 

treatment,  results  of,  274 

non-indin-aled,  270,  272 

operative  indications,  247 

sex  frefpiency,  245 

surgical  treatment,  299 


498 


INDEX    OF    SUBJECTS 


Ulcer  of  duodenum,  symptoms,  223 
treatment,  surgical,  299 
with  gall-bladder  and  liver  compli- 
cations, operation  in,  248 
with  gastric  complications,  opera- 
tion in,  248 
Ulceration     of     esophagus,     cicatricial 

stricture  from,  11,  12 
Urine  in  gall-stones,  444 
in  gastric  cancer,  95 


Valve   formation   in   pyloric   obstruc- 
tion, 50,  51,  90,  128,  142,  273 
Vestibule  of  small  intestines,  234 
Vicious  circle  after  gastro-enterostomy, 

138,  146,  258 
Vomiting  in  gastric  cancer,  64,  94 
ulcer,  224 
in  pyloric  obstruction,  64 
of  blood  as  sign  of  gastric  injury,  35 
regurgitant,  after  gastro-enterostomy, 
112,  138,  148,  258 
Doyen's    operation    for    preven- 
tion. 112 


Vomiting     regurgitant,     after     gastro- 
enterostomy, entero-anastomo- 
sis  in,  112,   138 
Rutkowski's    operation    to    pre- 
vent, 112 


Water,  value  of,  in  body,  311 
Water-bottle  stomach,  Bristow's,  97 
Wirsung's  duct,  235,  466 
W^itzel's  method  of  gastrostomy,  40 
in  gastric  cancer,  109 
operation   in   obstruction   of   cardiac 
orifice  of  stomach,  89 
Wblfler's  method  of  gastro-enterostomy, 
113 
operation   in   malignant   pyloric   ob- 
struction, 76 
Wounds,  gunshot,  of  liver,  346 

of  stomach,  gastrorrhaphy  in,  69 
of  stomach,  gastrorrhaphy  in,  38 
siirgery,  35 


X-RAYS.     See  Rontgen  rays. 


RD  14M45  C  1 

A  codec' 


